Establishing Normative Voice-Related Quality of Life Scores Within the Pediatric Otolaryngology Population

OBJECTIVE

To establish normative values for voice-related quality of life across a broad pediatric otolaryngology population using the Pediatric Voice Outcome Survey (PVOS).

DESIGN

Longitudinal study.

SETTING

Multiphysician outpatient pediatric otolaryngology practice.

METHODS

The PVOS was completed by 385 parents of children and adolescents aged 2 to 18 years. Of the 385 parents, 75 were readministered the instrument 2 weeks after no intervention had been provided. Data were collected regarding the patients' age, main diagnosis, and operative intervention.

RESULTS

The PVOS demonstrated robust internal consistency with an overall Cronbach alpha value of.70. Test-retest reliability demonstrated a weighted kappa value of 0.89 (95% confidence interval, 0.84-0.95) The mean +/- SD converted score (based on a 0-100 scale) for the overall population was 80.5 +/- 19.9. Converted PVOS scores are provided for each subpopulation according to main diagnosis. The PVOS scores varied significantly according to age (P<.05) and preoperative and postoperative status following adenoidectomy (P<.05).

CONCLUSION

The PVOS represents a valid and reliable instrument to measure voice-related quality of life in a broad pediatric otolaryngology population.

Pediatric endoscopic transnasal adenoid ablation

We describe a technique in which suction diathermy is used for adenoid ablation through a solely endoscopic transnasal approach in the older pediatric population. This procedure has proved to be both effective and convenient during other transnasal endoscopic procedures, as it provides excellent visualization of both the superior and inferior parts of the nasopharynx and results in minimal to no bleeding in the adenoid bed. In all cases to date, there has been complete resolution of preoperative problems of infection, pain, and bleeding. All patients had good control of postoperative pain. There has been no evidence of postoperative nasopharyngeal stenosis and no velopharyngeal insufficiency. Although transnasal adenoid ablation is not appropriate for the entire pediatric population, this procedure has multiple benefits when another endoscopic sinonasal procedure is planned, when there is neck instability, or when enhanced visualization of the nasopharynx is desired.

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.

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.

Congenital high airway obstruction syndrome and airway reconstruction: an evolving paradigm

OBJECTIVES

To refine the classic definition of, and provide a working definition for, congenital high airway obstruction syndrome (CHAOS) and to discuss the various aspects of long-term airway reconstruction, including the range of laryngeal anomalies and the various techniques for reconstruction.

DESIGN

Retrospective chart review.

PATIENTS

Four children (age range, 2-8 years) with CHAOS who presented to a single tertiary care children's hospital for pediatric airway reconstruction between 1995 and 2000.

CONCLUSIONS

To date, CHAOS remains poorly described in the otolaryngologic literature. We propose the following working definition for pediatric cases of CHAOS: any neonate who needs a surgical airway within 1 hour of birth owing to high upper airway (ie, glottic, subglottic, or upper tracheal) obstruction and who cannot be tracheally intubated other than through a persistent tracheoesophageal fistula. Therefore, CHAOS has 3 possible presentations: (1) complete laryngeal atresia without an esophageal fistula, (2) complete laryngeal atresia with a tracheoesophageal fistula, and (3) near-complete high upper airway obstruction. Management of the airway, particularly in regard to long-term reconstruction, in children with CHAOS is complex and challenging.

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.

Final validation of the Pediatric Tracheotomy Health Status Instrument (PTHSI)

OBJECTIVE

We sought to describe the development and final testing of an instrument designed to evaluate the impact of tracheotomy on the health-related quality of life of affected families in whom a child has had a tracheotomy (the Pediatric Tracheotomy Health Status Instrument [PTHSI]).

STUDY DESIGN

This cross-sectional study designed to analyze a disease-specific health status instrument to establish validity and reliability.

RESULTS

The PTHSI was initially pilot tested in 130 families during a 3-month period from September through November 2000. After initial analysis and revision, from January 2001 through July 2001, 154 different families completed the revised instrument. The overall Cronbach's alpha coefficient for the instrument was 0.91, with domain-specific coefficients ranging from 0.66 for physical symptoms to 0.87 for caregiver stress and coping. Specific criterion validity analysis produced a Pearson correlation coefficient of 0.8 (P < 0.0001). Construct validity testing via Wilcoxon matched sum testing suggested statistically significant differences between subpopulations (P < 0.001).

CONCLUSION

After initial testing and revision of the PTHSI, final instrument administration and analysis reveal the instrument to be valid and reliable. Future studies are planned to evaluate its responsiveness in longitudinal application.

Subglottic stenosis complicated by allergic esophagitis: case report

Allergic esophagitis is a known entity that had been described in patients with dysphagia. It has not been previously described in association with subglottic stenosis. We report the case of a 2-year-old girl with symptoms suggestive of allergic esophagitis who suffered from subglottic stenosis that recurred despite surgical measures. Her esophageal pH monitoring results were normal, and she did not respond to antireflux medications. She did respond dramatically to corticosteroid therapy with improvement of both her esophageal and laryngeal symptoms. Allergic esophagitis as a clinical entity is discussed.

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.

Endoscopic access to the infratemporal fossa and skull base: a cadaveric study

OBJECTIVES

To demonstrate that the regions of the infratemporal fossa and skull base at the level of the foramen ovale can be visualized endoscopically and that structures can be manipulated within these regions using endoscopic instruments.

METHODS

Cadaveric dissection of 3 human cadavers using an endoscopic optical dissector. In all, 6 endoscopic infratemporal fossa and skull base approaches were performed.

SETTING

Human temporal bone laboratory.

RESULTS

A Gillies incision was coupled with a lateral brow incision, and then subperiosteal planes were developed. Endoscopic visualization and instrumentation was then performed. The infratemporal fossa was readily identified. The skull base at the level of the foramen ovale and the branches of the third division of the trigeminal nerve were seen distinctly. A probe was placed with ease within the foramen ovale itself.

CONCLUSIONS

Endoscopic access to the infratemporal fossa is readily accomplished, with excellent visualization and instrumentation ability. This novel technique provides access to this remote region for evaluation, possible biopsy, and potential treatment of infratemporal fossa lesions.

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.

Functional magnetic resonance imaging of the pediatric swallow: imaging the cortex and the brainstem

OBJECTIVE

To design and implement a functional magnetic resonance imaging (fMRI) protocol to investigate the cortical and brainstem patterns of activity in children with regard to the act of swallowing.

STUDY DESIGN

Pilot study to assess the clinical feasibility of the project.

METHODS

Using a 3T Bruker Biospec 30/60 MRI scanner, images were obtained using the Behavior Interleaved Gradient/Blood Oxygen Level Dependent (BIG-BOLD) image acquisition method. Initially, regions of interest (ROI) were developed to identify the mean time from the onset of a swallow to maximum cortical blood flow in the motor cortex. Using this data to design the BIG-BOLD acquisition method followed by postprocessing of the data, images from two volunteer adults and four volunteer children were obtained.

RESULTS

The average time from the onset of a swallow to maximum cortical blood flow was 6 to 8 seconds. Regions of cortical activity include pre- and post-central gyrus (Brodmann's areas 3 and 4), superior motor cortex (B.A. 24), insula, inferior frontal cortex (B.A. 44 and 45), Heschl gyrus (B.A. 41 and 42), putamen, globus pallidus, and the superior temporal gyrus (B.A. 38). Of particular note is the first mapping of the functional activity of swallowing at the level of the brainstem; activity was seen in the region of the nucleus ambiguous.

CONCLUSIONS

fMRI provides a novel means of studying the central processes of both normal swallowing and its various pathologic forms in children. Further understanding of how a child coordinates a swallow and how this coordination can be altered at the level of the brainstem and cortex may aid in the development of novel rehabilitative strategies.

Preventing labyrinthitis ossificans: the role of steroids

OBJECTIVE

To identify a possible relationship between the administration of steroids at the time of diagnosis of bacterial meningitis and the development of labyrinthitis ossificans.

DESIGN

Retrospective analysis of the charts of 38 children requiring cochlear implantation who presented with bacterial meningitis and then developed bilateral profound deafness. The patients' charts were reviewed for age at diagnosis, the type of antibiotic administered, and the administration, dosage, and duration of steroid (dexamethasone) therapy. Labyrinthitis ossificans was established by preoperative computed tomographic and/or magnetic resonance imaging and by the intraoperative findings as described in the operative report.

PATIENTS AND METHODS

Patients were 38 children who received cochlear implantation by a single senior otolaryngologist for bacterial meningitis-related deafness. Ten patients' charts (26%) were available for full review; 9 of these 10 patients had documented pneumococcal meningitis and the other patient had Haemophilus influenzae-type meningitis.

RESULTS

One of the 6 patients who received steroid therapy at the time of initial illness had documented evidence of labyrinthitis ossificans either radiographically or at the time of surgery. All 4 patients who failed to receive steroid therapy developed labyrinthitis ossificans. The results achieve statistical significance by chi2 analysis and a t test (P<.01).

CONCLUSION

The results of this retrospective study are highly suggestive of a role for steroids in preventing the development of labyrinthitis ossificans in children with pneumococcal meningitis.

Methicillin-resistant Staphylococcus aureus otorrhea after tympanostomy tube placement: an emerging concern

OBJECTIVES

To review the treatment of pediatric patients with methicillin-resistant Staphylococcus aureus (MRSA)-positive cultures as a result of otorrhea after tympanostomy tube placement in terms of both medication and isolation strategies and to highlight an emerging problem faced by the clinician with reference to treatment options as well as to the treatment of these patients in an outpatient setting.

PATIENTS

Between December 1998 and January 2000, a total of 8 children between the ages of 1 and 11 years had MRSA-positive cultures as a result of otorrhea after tympanostomy tube placement.

MAIN OUTCOME MEASURES

The Department of Infectious Diseases was notified, and a variety of topical antibiotic treatments were administered. Arch Otolaryngol Head Neck Surg. 2000;126:1440-1443

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.

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.

Subglottic stenosis associated with transesophageal echocardiography

Transesophageal echocardiography (TEE) is used extensively to assess cardiac function and anatomical relationships in both adults and children. Although considered a noninvasive procedure, TEE in infants and small children may result in airway complications. A patient who developed subglottic stenosis after the use of TEE during a cardiac procedure is reported.

Reversible sensorineural hearing loss following administration of muromonab-CD3 (OKT3) for cadaveric renal transplant immunosuppression

This prospective study is a follow-up to a case report noting reversible sensorineural hearing loss after administration of OKT3 for immunosuppression in a steroid-resistant renal cadaveric transplant patient who was rejecting his transplant. The objective is to determine the interval estimate for incidence of sensorineural hearing loss following treatment with OKT3. Seven patients were admitted to the Renal Transplant Service at Montefiore Medical Center from July 1996 to July 1997 with steroid-resistant rejection of renal cadaveric transplants and received OKT3 as an immunosuppressant. All 7 patients received 3 audiograms: the first, prior to the administration of the first dose of OKT3, the second, 48 to 72 hours after administration of OKT3, and the third, approximately 2 weeks after administration of OKT3. Five of the 7 patients (71%) demonstrated a sensorineural hearing loss of 15 dB or greater at frequencies of 8 to 12 kHz. Four of the 5 patients with audiographic changes had near-complete to complete recovery of their high-frequency thresholds after discontinuation of the drug regimen. In conclusion, OKT3 can cause sensorineural hearing loss. This side effect is mainly reversible after 2 weeks following discontinuation of the drug. Patients receiving OKT3 should be forewarned of this possible side effect prior to the administration of OKT3.

Reversible sensorineural hearing loss after renal transplant immunosuppression with OKT3 (muromonab-CD3)

Reversible and irreversible ototoxicity has been documented following the administration of various therapeutic agents. Reversible hearing loss is a known complication following the administration of quinine, salicylates and other nonsteroidal anti-inflammatory drugs, and erythromycin. We report a case of reversible hearing loss following OKT3 (murine monoclonal antibody CD3) administration. OKT3, a monoclonal antibody used as an immunosuppressant following cadaveric renal transplants, was associated with a transient sensorineural hearing loss that reversed following discontinuation of OKT3.