Laryngeal ultrasound and vocal fold movement in the pediatric cardiovascular intensive care unit

Paediatric Laryngeal Ultrasound: A Retrospective Cohort Study in Aotearoa New Zealand and an International Survey

OBJECTIVE

Vocal fold immobility (VFI) is a cause of significant morbidity and mortality in the paediatric population. Laryngoscopy is the current first-line investigation for patients with suspected VFI. Laryngeal ultrasound (LUS) has recently emerged as an alternative method of identifying VFI. Compared to laryngoscopy, LUS is less invasive, does not require anaesthesia, and can be performed by non-otolaryngologists. The objectives of this study are to evaluate LUS as a diagnostic method for the identification of VFI in a cohort of paediatric patients in Aotearoa New Zealand (NZ) and to estimate the frequency of use of LUS in the paediatric population by clinicians around the world.

METHODS

A retrospective, single-centre cohort study was performed on all paediatric patients who had undergone laryngoscopy and LUS at Starship Children's Health in Auckland, NZ, between 2020 and 2023. An eight-question survey was also developed and distributed to better understand clinicians' use of LUS in their clinical practice to diagnose paediatric VFI globally.

RESULTS

Twenty-nine paediatric patients met the inclusion criteria. LUS demonstrated good sensitivity (80.95%) for detecting VFI and increased to 93.33% for the detection of unilateral VFI. Of the 87 respondents to the survey, 41.38% utilise LUS in their clinical practice in the paediatric population. The main barriers to implementation of LUS as identified by non-users were lack of equipment, expertise, and training.

CONCLUSIONS

These findings support the use of LUS as an accurate diagnostic tool for the detection of unilateral VFI. Further studies in non-surgical populations and in patients with bilateral VFI, as well as standardised guidelines for LUS technique and reporting, are required.

Comparison of the diagnostic and prognostic abilities of flexible laryngoscopy and dynamic digital radiography for vocal cord paralysis: A prospective observational study

BACKGROUND

Although flexible laryngoscopy (FL) is the reference modality for diagnosing vocal cord paralysis (VCP), FL involves patient discomfort and insertion intolerance. Dynamic digital radiography (DDR) with high spatial and temporal resolution is easier to use and less invasive when evaluating VCP.

METHODS

Seventy-eight patients underwent FL and DDR before and after neck surgery. Qualitative and quantitative vocal cord movement (VCM) evaluations were conducted. Patients with postoperative VCP were followed-up regularly.

RESULTS

DDR exhibited diagnostic performance with 67% sensitivity and 100% specificity. The cutoff for VCM was 2.4 mm, with DDR exhibiting 100% sensitivity and 78% specificity. All cords with transient VCP had positive VCM at both 3 weeks and 2 months. Additionally, 50% and 75% of cords with permanent VCP had negative VCM at 3 weeks and 2 months, respectively.

CONCLUSIONS

DDR is promising for the diagnosis of postoperative VCP and early prediction of permanent postoperative VCP.

Ultrasound Screening After Cardiac Surgery Shows Vocal Fold Impairment and Predicts Aspiration

INTRODUCTION

Vocal fold motion impairment (VFMI) is a known consequence after high-risk cardiac surgery. We implemented a universal laryngeal ultrasound (LUS) screening protocol for VFMI after the Norwood and aortic arch surgery. We hypothesized that LUS would accurately identify VFMI and predict postoperative aspiration.

METHODS

We implemented a screening algorithm with LUS for patients undergoing high-risk cardiac surgery at a tertiary care pediatric hospital. Positively screened patients underwent flexible nasolaryngoscopy (FNL). Patients with an abnormal FNL underwent a video-fluoroscopic swallow study (VFSS). Patient demographics, length of stay, and swallowing outcomes were assessed. Two-tailed chi square and Wilcoxon rank sum tests were used to assess for differences.

RESULTS

Sixty-seven patients underwent either Norwood or arch reconstruction over a 16-month period and underwent universal LUS. The average birth weight was 3.24 kg (SD 0.57). Of the 67 patients, VFMI was identified by LUS and 100% confirmed on FNL in 58.21% (n = 39/67) of patients. Aspiration and penetration on VFSS were higher in the group with VFMI as compared with those without VFMI (53.8% vs. 21.4%, p = 0.008). There was no difference in length of stay between patients who did not have a diagnosis of VFMI and those found to have VFMI (41.0 days vs 45.3 days p = 0.73).

CONCLUSIONS

Universal LUS screening for patients following high-risk cardiac surgery may lead to earlier identification of postoperative VFMI and aspiration. Recognition of VFMI through this universal screening program could lead to earlier interventions and possibly improved swallowing outcomes.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:1939-1944, 2024.

Clinical Prognosis of Vocal Cord Paralysis After Cardiothoracic Surgery in Infants

We aimed to clarify the long-term outcomes and prognosis of vocal cord paralysis (VCP) after cardiothoracic surgery in infants as well as the usefulness of laryngeal ultrasound (LUS) as screening for VCP. Overall, 967 infants aged 1-year-old or younger who underwent cardiothoracic surgery between 2008 and 2022 were included in this study. We divided the patients into two groups based on the period on whether they underwent screening without or with LUS and compared the incidence of VCP between the groups. There were no differences in the patients' preoperative characteristics between the two periods, whereas the incidence of VCP was significantly higher in period 2 than in period 1 (11.0% vs. 3.2%, p < 0.0001). The incidence of VCP among the procedures, including aortic arch repair, was > 50% and significantly increased from period 1 to period 2. The sensitivity and specificity of LUS was 87% and 90%, respectively. Symptoms of VCP improved in 92% of patients. Repeated flexible laryngoscopy revealed that the residual rate of VCP was 68%, 52%, and 48% at 6, 12, and 24 months, respectively. In conclusion, symptoms of postoperative VCP improved in most cases; however, paralysis persisted in half of the patients. As a screening method, LUS is useful for evaluating postoperative VCP. A more accurate understanding of VCP is needed to improve postoperative outcomes.

The vocal cords are predominantly closed in preterm infants <30 weeks gestation during transition after birth; an observational study

AIM

Studies in animals have shown that vocal cords (VCs) close during apnoea before and after birth, thereby impairing the effect of non-invasive ventilation. We tested the feasibility of visualising VCs using ultrasonography (US) and investigated the position and movement of the VCs during non-invasive respiratory support of preterm infants at birth.

METHODS

In an observational study, VCs were visualised using US in infants <30 weeks gestation during both stabilisation after birth and at one hour after birth. Respiratory efforts were simultaneously recorded. The percentage of time the VCs were closed in the first ten minutes was determined from videoframes acquired at 15 Hz and compared with respiratory flow patterns measured using a respiratory function monitor.

RESULTS

US of the VCs could be performed in 20/20 infants included (median (IQR) gestational age 27+6 (27+1-28+6) weeks) without interfering with stabilisation, of whom 60% (12/20) were initially breathing and 40% (8/20) were apnoeic at birth. In breathing infants, the VCs closed between breaths and during breath holds, which accounted for 57% (49-66) of the time. In apnoeic infants receiving positive pressure ventilation, the VCs were closed for 93% (81-99) of the time. US at one hour after birth could be performed in 14/20 infants, VCs were closed between breaths and during breath holds, accounting for 46% (27-52) of the time.

CONCLUSION

Visualising VCs in preterm infants at birth using US is feasible. The VCs were closed during apnoea, in between breaths and during breath holds, impairing the effect of ventilation given.

Diagnostic Accuracy of Laryngeal Ultrasound for Evaluating Vocal Fold Movement Impairment in Children

PURPOSE

Vocal fold movement impairment (VFMI) secondary to recurrent laryngeal nerve (RLN) injury is a common source of morbidity after pediatric cervical, thoracic, and cardiac procedures. Flexible laryngoscopy (FL) is the gold standard to diagnose VFMI yet can be challenging to perform and/or risks possible clinical decompensation in some children and is an aerosolizing procedure. Laryngeal ultrasound (LUS) is a potential non-invasive alternative, but limited data exists in the pediatric surgical population regarding its efficacy. We aimed to investigate the diagnostic accuracy of LUS compared to FL in evaluating VFMI.

METHODS

A prospective, single-center, single-blinded (rater) cohort study was undertaken on perioperative pediatric patients at risk for RLN injury. Patients underwent FL and LUS. Cohen's kappa was used to determine chance-corrected agreement.

RESULTS

Between 2021 and 2023, 85 paired evaluations were performed with patients having a median (IQR) age of 10 (4, 42) months and weight of 7.5 (5.4, 13.4) kilograms. The prevalence of VFMI was 27.1%. Absolute agreement between evaluations was 98.8% (kappa 0.97, 95% CI: 0.91-1.00, P < 0.001). The sensitivity and specificity of LUS in detecting VFMI was 95.7% and 100%, yielding a positive predictive value (PPV) of 100% and negative predictive value (NPV) of 98.4% (95% CI: 90-100%). Diagnostic accuracy was 98.8% (95% CI: 93-100%).

CONCLUSION

LUS is a highly accurate modality in evaluating VFMI in children. While FL remains the gold standard for diagnosis, LUS offers a low-risk screening modality for children at risk for VFMI such that only those with an abnormal LUS or presence of clinical symptoms discordant with LUS findings should undergo FL.

TYPE OF STUDY

Prospective, single-center, single blinded (rater), cohort study.

LEVEL OF EVIDENCE

Level II.

Screening for Vocal Fold Movement Impairment in Children Undergoing Esophageal and Airway Surgery

INTRODUCTION

Children undergoing cervical and/or thoracic operations are at risk for recurrent laryngeal nerve injury, resulting in vocal fold movement impairment (VFMI). Screening for VFMI is often reserved for symptomatic patients.

OBJECTIVE

Identify the prevalence of VFMI in screened preoperative patients prior to an at-risk operation to evaluate the value of screening all patients at-risk for VFMI, regardless of symptoms.

METHODS

A single center, retrospective review of all patients undergoing a preoperative flexible nasolaryngoscopy between 2017 and 2021, examining the presence of VFMI and associated symptoms.

RESULTS

We evaluated 297 patients with a median (IQR) age of 18 (7.8, 56.3) months and a weight of 11.3 (7.8, 17.7) kilograms. Most had a history of esophageal atresia (EA, 60%), and a prior at-risk cervical or thoracic operation (73%). Overall, 72 (24%) patients presented with VFMI (51% left, 26% right, and 22% bilateral). Of patients with VFMI, 47% did not exhibit the classic symptoms (stridor, dysphonia, and aspiration) of VFMI. Dysphonia was the most prevalent classic VFMI symptom, yet only present in 18 (25%) patients. Patients presenting with a history of at-risk surgery (OR 2.3, 95%CI 1.1, 4.8, p = 0.03), presence of a tracheostomy (OR 3.1, 95%CI 1.0, 10.0, p = 0.04), or presence of a surgical feeding tube (OR 3.1, 95%CI 1.6, 6.2, p = 0.001) were more likely to present with VFMI.

CONCLUSION

Routine screening for VFMI should be considered in all at-risk patients, regardless of symptoms or prior operations, particularly in those with a history of an at-risk surgery, presence of tracheostomy, or a surgical feeding tube.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:3564-3570, 2023.

Advanced imaging and modeling in neonatal simulation

Advances in modeling and imaging have resulted in realistic tools that can be applied to education and training, and even direct patient care. These include point-of-care ultrasound (POCUS), 3-dimensional and digital anatomic modeling, and extended reality. These technologies have been used for the preparation of complex patient care through simulation-based clinical rehearsals, direct patient care such as the creation of patient devices and implants, and for simulation-based education and training for health professionals, patients and families. In this section, we discuss these emerging technologies and describe how they can be utilized to improve patient care.

Nutrition for critically ill children with congenital heart disease

Children with congenital heart disease often require admission to the cardiac intensive care unit at some point in their lives, either after elective surgical or catheter-based procedures or during times of acute critical illness. Meeting both the macronutrient and micronutrient needs of children in the cardiac intensive care unit requires complex decision-making when considering gastrointestinal perfusion, vasoactive support, and fluid balance goals. Although nutrition guidelines exist for critically ill children, these cannot always be extrapolated to children with congenital heart disease. Children with congenital heart disease may also suffer unique circumstances, such as chylothoraces, heart failure, and the need for mechanical circulatory support, which greatly impact nutrition delivery. Guidelines for neonates and children with heart disease continue to be developed. We provide a synthesized narrative review of current literature and considerations for nutrition evaluation and management of critically ill children with congenital heart disease.

Morbidity and mortality among neonates with esophageal atresia and/or tracheoesophageal fistula in the United States

BACKGROUND

Although rare, esophageal atresia (EA) and/or tracheoesophageal fistula (TEF) can lead to severe morbidity and mortality. A known complication of EA and/or TEF repair is vocal fold motion impairment (VFMI).

OBJECTIVE

To characterize the prevalence of VFMI among repaired EA and/or TEF at a national level and to identify factors associated with in-patient mortality and common clinical endpoints in this population (tracheostomy and gastrostomy tube dependence).

METHODS

This is a retrospective cohort study of inpatient neonate admissions with EA and/or TEF in the 2016 Kids' Inpatient Database (KID). Patients with a history of EA and/or TEF were identified with ICD-10 codes. VFMI prevalence was assessed by observed frequencies and percentages. Clinical endpoints included gastrostomy (G-)tube placement, tracheostomy status, and inpatient mortality. Potential predictors of these three primary outcomes included cardiac anomalies, airway disorders, chromosomal anomalies, surgery within 24 h of admission, prematurity, and low birthweight (LBW). Chi-squared analysis was performed between each parameter and the primary outcomes. Significant associations (p-value<0.05) were further assessed with multivariate logistic regression.

RESULTS

Of 1062 neonates with history of EA and/or TEF, 24 (2.3%) had VFMI. Among this population, 27 patients underwent tracheostomies and 63 required G-tubes. There was a significantly higher likelihood of tracheostomy in patients with VFMI compared to patients without (16.7% versus 2.2%; p < 0.01). After multivariate analysis, birthweight less than 1.5 kg (BW < 1.5 kg; OR = 2.5, 95% CI: 1.03-6.10), extreme prematurity (OR = 7.5, 95% CI: 2.00-28.07), cardiac anomalies (OR = 1.8, 95% CI: 1.01-3.04) and chromosomal anomalies (OR = 4.2, 95% CI: 2.39-7.44) were significantly associated with in-hospital mortality. Bronchopulmonary dysplasia (BPD; OR = 4.7, 95% CI: 1.73-12.78) and BW < 1.5 kg (OR = 2.4, 95% CI: 1.05-5.49) were significant predictors for G-tube status. For tracheostomy, BPD (OR = 15.8, 95% CI: 4.70-52.83) and subglottic stenosis (SS, OR = 11.2, 95% CI: 1.85-68.02) remained significant predictors after multivariate regression.

CONCLUSION

The national prevalence of VFMI among neonates following EA and/or TEF repair was 2.3% and was associated with an increased likelihood of tracheostomy in the KID 2016. Significant predictors of in-hospital mortality were cardiac anomalies, chromosomal anomalies, extreme prematurity, and BW < 1.5 kg. BPD and SS were significant predictors of tracheostomy, and BPD and BW < 1.5 kg were significant predictors for G-tube requirements.

Ultrasound Assessment of Larynx and Trachea in the Neonatal Period, Examination Standard with Predictive Values-Study Protocol

Diseases of the larynx and trachea are a heterogenous group of disorders. Their diagnosis frequently requires invasive methods. Ultrasound is a non-invasive, repeatable and safe diagnostic method, which has recently, thanks to the development of technology, provided for very accurate imaging of even small structures, as well as their assessment on dynamic examination. Ultrasound examination of the larynx and trachea will be performed in 2022-2023 in a group of randomly selected 300 stable neonates born between 32 and 42 weeks of gestation. The results of this study will be presented after data collection in accordance with the adopted methodology. To date, this will be the first study to describe the ultrasound anatomy of the larynx and trachea and to establish reference ranges for the size of individual structures of the larynx and trachea in the neonatal population. We expect that our study will contribute to the further development of this part of ultrasonography and will reduce the number of invasive procedures performed in the diagnostics of these organs in the future. This manuscript is a study protocol registered at ClinicalTrials.gov (Identifier NCT05636410) and approved by the Bioethics Committee of the Medical University of Warsaw (KB 65/A2022).

Dysphagia Outcomes Following Surgical Management of Unilateral Vocal Fold Immobility in Children: A Systematic Review

OBJECTIVE

To assess dysphagia outcomes following surgical management of unilateral vocal fold immobility in children.

DATA SOURCES

Ovid Medline, Embase, Web of Science, and CENTRAL databases.

REVIEW METHODS

A systematic review of the medical literature was performed following the PRISMA guidelines. An a priori protocol was defined to identify all articles that presented quantifiable outcome data in children aged <18 years who underwent surgical treatment to improve glottal competence for dysphagia. Two authors independently determined references meeting the inclusion criteria, extracted data, and assigned levels of evidence. Data were pooled via a random effects model where possible. The quality of studies was graded with the MINORS criteria.

RESULTS

An overall 398 publications were screened, with 9 meeting inclusion criteria. A total of 115 patients were included. Of these, 75% had preoperative swallowing symptoms. Surgical intervention for dysphagia included 61 injection laryngoplasties, 11 medialization laryngoplasties, and 10 reinnervations (ansa cervicalis to recurrent laryngeal nerve). The articles consistently reported success in improving dysphagia symptoms, and limited meta-analysis demonstrated a mean improvement after surgical intervention in 79% (95% CI, 67%-91%) of children. The reported rate of minor and major complications was 15% (95% CI, 1%-29%). The MINORS scores ranged from 5 to 12.

CONCLUSION

Surgical management of unilateral vocal fold immobility in properly selected children can be an effective treatment for dysphagia when symptoms are present. Selection of surgical modalities relies on patient- and surgeon-related factors, and the rate of success is high across different interventions in treating these complex children.

Contemporary Use of Ultrasonography in Acute Care Pediatrics

Use of ultrasonography by clinicians at the point of care has expanded widely and rapidly. Pediatric acute care providers now leverage this valuable tool to guide procedures, diagnose pathophysiologic processes, and inform time-sensitive decisions in sick and unstable children. However, the deployment of any new technology must be packaged with training, protocols, and safeguards to optimize safety for patients, providers, and institutions. As ultrasonography is increasingly incorporated into residency, fellowship, and even medical student curricula, it is important that educators and trainees are aware of the diversity of its clinical applications. This article aims to review the current state of point-of-care ultrasonography in acute care pediatrics, with an emphasis on the literature supporting the use of this important clinical tool.

Improving Timeliness of Vocal Fold Mechanical Injury Screening Following Norwood or Arch Reconstruction: A Quality Improvement Initiative at a Single Center

Vocal fold (VF) immobility is a common complication after pediatric cardiothoracic surgeries involving the aortic arch and conotruncal region. Nasolaryngoscopy is considered the standard for diagnosis but is invasive and requires expertise and special resources. VF ultrasound (VF US) is an efficient, non-invasive alternative for VF evaluation in the post-cardiac surgical setting. Our aim was to improve screening rates for vocal fold motion impairment (VFMI) by implementing VF US in a group of pre-identified high-risk patients after index cardiac surgeries using Quality Improvement (QI) methodology. The QI project included formation of a widely representative stakeholder team, collaborative development of a screening protocol for the cohort of patients in our tertiary center. Baseline data were derived by retrospective review of screening and incidence of VFMI in a similar post-surgical cohort in 2 years prior to this intervention. We implemented an US screening algorithm with multidisciplinary care coordination. We evaluated feeding practices and length of stay (LOS) related to our screening interventions and documented follow up practices. Screening for VFMI by ultrasound increased from 59 to 92% after implementation of the VF screening protocol. Additionally, time between extubation and VF US decreased from 7.7 to 2.3 days. The positive predictive value of VF US was 96%. Patients with VFMI had a longer LOS and greater dependence on tube feeds at discharge after index surgery. We successfully implemented an ultrasound-based screening protocol for VFMI and demonstrated improved screening, timeliness and high positive predictive value of ultrasound.

Vocal cord dysfunction after pediatric cardiac surgery: A prospective implementation study

Objective

To determine the incidence, outcomes, and evaluate diagnostic modalities for postoperative vocal cord dysfunction (VCD) following cardiothoracic surgery in children.

Methods

A prospective mixed-methods study using principles of implementation science was completed. All patients undergoing surgery involving the aortic arch, ductus, or ligamentum arteriosum and vascular rings from September 2019 to December 2020 were enrolled. Patients underwent speech pathology assessment, laryngeal ultrasound, and flexible direct laryngoscopy.

Results

Ninety-five patients were eligible for inclusion. The incidence of VCD ranged from 18% to 56% and varied according to procedure group. VCD occurred in 42% of neonates. Repair of hypoplastic aortic arch was associated with increased risk of VCD (57%; P = .002). There was no significant difference in duration of intubation, pediatric intensive care unit stay, or hospital stay. Forty percent children were able to achieve full oral feeding. Children with VCD were more likely to require nasogastric supplementary feeding at discharge (60% vs 36%; P = .044). Sixty-eight percent of patients demonstrated complete resolution of VCD at a median of 97 days postoperatively. Laryngeal ultrasound and speech pathology assessment combined had a sensitivity of 91% in comparison to flexible direct laryngoscopy.

Conclusions

VCD occurred in one-third and resolved in two-thirds of patients at a median of 3 months following cardiac surgery. Aortic arch repair carried the highest risk of VCD. VCD adversely influenced feeding. Forty percent of patients achieved full oral feeding before discharge. VCD did not delay intensive care unit or hospital discharge. Speech pathology assessment and laryngeal ultrasound combined was reliable for diagnosis in most patients and was more patient friendly than flexible direct laryngoscopy.

Feasibility and accuracy of laryngeal ultrasound for the assessment of vocal cord mobility in children

OBJECTIVE

Transcutaneous laryngeal ultrasonography has been utilized to document vocal cord mobility in the adult perioperative thyroidectomy setting with variable success. The aims of this study were to assess the feasibility of using transcutaneous ultrasound in vocal cord visualization in children, to determine the accuracy in detecting vocal cord immobility compare to flexible laryngoscopy, and to identify any barriers that may affect its utility.

METHODS

This is a prospective blinded-assessor study. Transcutaneous laryngeal ultrasound and flexible laryngoscopy were performed in two pediatric settings: perioperative thyroid surgery and inpatient consultation for airway, voice, or swallowing concerns. The video recordings of ultrasound and laryngoscopy were assessed by two fellowship-trained pediatric otolaryngologists independently.

RESULTS

A total of 83 paired laryngoscopy and ultrasound assessments were performed, 39 for perioperative thyroidectomy and 44 for inpatient consultation. The majority had normal vocal cord mobility (65/83, 78%), while 16 had unilateral cord palsy and 2 had bilateral palsy. The vocal cords were successfully visualized on ultrasound in 82/83 (99%) evaluations. Compared to gold standard laryngoscopy, the sensitivity for diagnosing vocal cord palsy on ultrasound was 53-83%, and the specificity was 97-98%. The sensitivity for detecting asymmetric vocal cord movement was 56-88%, and the specificity was 99%. The agreement between ultrasound and laryngoscopy diagnoses were 87-94% (κ = 0.58-0.83, moderate to near perfect agreement). The intra-rater agreement was 95-100% (κ = 0.64-1.0), and inter-rater agreement was 90% (κ = 0.66). Both subjects with bilateral vocal cord palsy had incorrect ultrasound diagnoses by both observers.

CONCLUSION

We were able to utilize transcutaneous laryngeal ultrasound to successfully visualize vocal cord mobility in almost all pediatric patients with a high degree of specificity. The modality has limitations in the assessment of bilateral vocal cord palsy, and its sensitivity was observer-dependent.

Ultrasound of the vocal cords in infants

Vocal cord paralysis is a common cause of respiratory and feeding problems in the pediatric population. While the causes of vocal cord paralysis are multiple, iatrogenic injury of the recurrent laryngeal nerve after cardiovascular surgery is the most frequent cause. Vocal cord paralysis increases the risk of swallowing dysfunction, tracheal aspiration and pneumonia. It also increases the need for nasoenteric feeds and gastrostomy tube placement. Flexible nasopharyngolaryngoscopy is considered the gold standard for diagnosing vocal cord paralysis, but it has significant drawbacks: it is uncomfortable, it can trigger a cardiovascular event in children with unstable cardiovascular status, it can be challenging to perform, and it can be difficult to interpret. Laryngeal US has become a popular imaging modality to evaluate the function of the vocal cords. Laryngeal US is well-tolerated, easy to perform, simple to interpret and has a lower physiological impact compared to flexible nasopharyngolaryngoscopy. Laryngeal US is an accurate and low-cost diagnostic test for vocal cord paralysis. In this review, we describe the anatomy of the larynx and recurrent laryngeal nerve; the causes, symptoms and pathophysiology of vocal cord paralysis; laryngeal US technique; diagnostic criteria for vocal cord paralysis; and a reporting system.

Bilateral recurrent laryngeal nerve paralysis diagnosed using dynamic digital radiography during the COVID-19 pandemic

Dynamic digital radiography (DDR) is a motion-detecting technique with high temporal resolution. Flexible laryngoscopy is a common modality for the observation of the larynx; however, it generates aerosol. DDR is an easy and less risky screening test for the diagnosis of recurrent laryngeal nerve paralysis during the COVID-19 pandemic.

Pre- and Postoperative Ultrasound and MRI Examinations in Assessing Vocal Folds in Patients with Goiter

Aim of the study: To determine the value of dynamic examinations ultrasound (US) and MRI in the 1.5T field in the assessment of the mobility of vocal folds (VF) in comparison to laryngoscopy in patients with thyroid gland resection. Materials and methods: A total of 44 patients with goiter, before and after thyroidectomy, were subjected to videolaryngoscopy and dynamic examinations of the vocal folds using ultrasound and the following MRI sequences: generic gradient echo (GRE) and true fast imaging with steady-state precession (TRUFI). The qualitative and quantitative data were analyzed, i.e., the angles of deviation from the midline of the vocal folds and the area of the right and left rima glottidis compartments. Results: The analysis of qualitative data showed that the results obtained by laryngoscopy, US and MRI are independent of the diagnostic method used in the group of patients pre and post thyroidectomy. Between the pre- and postoperative examinations in the group of paralyzed vocal folds, statistically significant differences were found in the minimum and maximum values of the angles for the MRI-GRE and MRI-TRUFI sequences and the maximum value of the angles in the US examination, but also in the maximum value of the area of the glottis compartments in both MRI-GRE and MRI-TRUFI dynamic sequences and the minimum value of the area in the sequence MRI-GRE. Statistically significant differences were found in both MRI sequences during phonation, both for the value of the angles and the area of the affected vocal folds. However, no statistically significant differences were found in the values of the angles or the areas in both vocal fold imaging methods without identified mobility abnormalities. Conclusions: Ultrasound and MRI examinations using dynamic sequences have a similar diagnostic value to laryngoscopy in the assessment of vocal fold paralysis in patients with goiter. The GRE sequence seems to be the most reliable one in determining vocal fold paralysis, and the most reliable parameter is the maximum area of the rima glottidis compartment. The inclusion of dynamic short sequences widely available in 1.5T scanners in standard neck examination protocols represents a novelty of the method and a promising diagnostic perspective in the diagnosis of vocal fold paralysis.

Enhanced rapid review of the applicability of ultrasound in the assessment of sucking, swallowing and laryngeal function in the paediatric population

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has renewed interest in the use of ultrasound (US) amongst dysphagia-trained clinicians working with infants and children. US is a portable, minimally intrusive tool which carries reduced risk of aerosol-generation provoked by other instrumental swallowing assessment tools such as fibreoptic endoscopic evaluation of swallowing (FEES). For this reason, US could be a valuable addition to the dysphagia assessment toolkit. A recently published rapid review of US evidence for the assessment of swallowing and laryngeal function in the adult population provided a framework for this neonatal and paediatric review.

AIMS

This enhanced rapid review aimed to establish the applicability of US as an instrumental assessment tool for sucking, swallowing and laryngeal function in the neonatal and paediatric populations.

METHODS & PROCEDURES

A rapid review of six electronic databases was conducted to identify articles using US to assess sucking, swallowing or laryngeal function in the selected populations, compared with varied reference tests. Abstract screening was completed according to pre-defined inclusion/exclusion criteria with 10% of articles assessed by a second screener. Data was extracted from the included studies using a pre-developed form. A modified QUADAS-2 tool was used to assess study quality. Results from the included studies were summarised and grouped into sucking, swallowing and laryngeal function data.

OUTCOMES & RESULTS

Twelve studies using US in the assessment of swallowing and/or laryngeal function met inclusion criteria. No studies using US for assessment of sucking met the inclusion criteria. All were peer-reviewed, primary studies across a range of clinical populations and with a wide geographical spread. Five studies had an overall low risk of bias. Seven studies had at least one domain where risk of bias was judged as high. All studies had high applicability. The two studies assessing swallowing differed in terms of aims and use of US. The studies assessing laryngeal function predominately investigated vocal fold movement and laryngeal pathology. Sensitivity and specificity data were provided or calculated from raw data for nine of the laryngeal function studies (respective ranges of 75%-100% and 80%-100%).

CONCLUSIONS & IMPLICATIONS

Emerging evidence exists to support the use of US as adjunct to clinical assessment of swallowing and laryngeal function in the neonatal and paediatric population. A paucity of evidence to support use of US in the assessment of sucking exists. Further research is needed to establish evidence-based assessment and analysis protocols as well as development of paediatric data.

Assessment of Vocal Cord Motion Using Laryngeal Ultrasound in Children: A Systematic Review and Meta-Analysis

OBJECTIVES

Laryngeal ultrasound is a nonirradiating, noninvasive method for assessing the upper airway in children. This systematic review and meta-analysis examine available evidence for accuracy of laryngeal ultrasound in diagnosing vocal cord immobility in infants and children after surgery and trauma affecting the vocal cords.

DESIGN

Medical subject heading terms were used to search MEDLINE, Embase, Google Scholar, Web of Science, and the Cochrane Library for relevant citations. Publications from January 1, 2000, to June 30, 2020 were included in the search strategy. Study inclusion criteria consisted of randomized control trials and nonrandomized retrospective or prospective observational studies where vocal cord motion was evaluated by laryngeal ultrasound and compared with a reference test. Studies were excluded if there was insufficient data to compute a sensitivity/specificity table. Case reports, case series less than 10, and manuscripts not published in English were also excluded.

PATIENTS

Studies which included subjects younger than or equal to 18 years were considered for full article review.

SETTINGS

No restrictions on study settings were imposed in this systematic review.

MEASUREMENTS AND MAIN RESULTS

The initial search returned 1,357 citations. After de-duplication, abstract, and full review, eight citations were included in the final meta-analysis. A bivariate random-effects meta-analysis was performed, which revealed a pooled sensitivity for laryngeal ultrasound in detecting vocal cord immobility of 91% (95% CI, 83-95%), specificity of 97% (95% CI, 82-100%), diagnostic odds ratio 333.56 (95% CI, 34.00-3,248.71), positive likelihood ratio 31.58 (95% CI, 4.50-222.05), and negative likelihood ratio 0.09 (95% CI, 0.05-0.19).

CONCLUSIONS

Laryngeal ultrasound demonstrates high sensitivity and specificity for detecting vocal cord motion in children in a wide range of clinical settings. Laryngeal ultrasound offers a low-risk imaging option for assessing vocal cord function in children compared with the current gold standard of laryngoscopy.

The utility of handheld ultrasound as a point-of-care screening tool to assess vocal fold impairment following congenital heart surgery

INTRODUCTION

Vocal fold motion impairment (VFMI) is a known potential complication of congenital heart surgery (CHS). Flexible nasolaryngoscopy (FNL) is the gold standard for evaluation of vocal fold movement but has risks, including epistaxis, desaturation, and changes in heart rate. Laryngeal ultrasound (LUS) has begun to emerge as a diagnostic tool and has been shown to have high accuracy in the evaluation of VFMI. We sought to assess the utility of hand-held LUS as a point-of-care screening tool to assess VFMI in pediatric patients following congenital heart surgery.

METHODS

Using a prospective cohort design, children under 18 years who were undergoing congenital heart surgery at a tertiary care pediatric hospital were enrolled. All patients underwent postoperative LUS and FNL. All studies were reviewed by two otolaryngology reviewers blinded to the clinical diagnosis. Higher quality studies were reviewed by two cardiology reviewers also blinded to the clinical diagnosis. Accuracy and inter-rater reliability were calculated.

RESULTS

Sixty-two children were screened. Fourteen children with VFMI were identified via FNL. When comparing LUS and FNL, both individual accuracy (90.3% and 75.8%) and interrater agreement (79% overall, 96% for high quality videos) were high for the otolaryngology reviewers. The cardiology reviewers were able to obtain 100% accuracy for high quality videos.

CONCLUSION

Handheld LUS has utility as a point-of-care screening tool to assess VFMI. This may have benefit in low-resource settings, for universal screening in cardiac intensive care units, or in settings where otolaryngology consultation may be difficult to obtain.

Vocal Fold Movement and Silent Aspiration After Congenital Heart Surgery

OBJECTIVES/HYPOTHESIS

Infants who undergo congenital heart surgery are at risk of developing vocal fold motion impairment (VFMI) and swallowing difficulties. This study aims to describe the dysphagia in this population and explore the associations between surgical complexity and vocal fold mobility with dysphagia and airway protection.

STUDY DESIGN

Retrospective chart review.

METHODS

This is a retrospective chart review of infants (age <12 months) who underwent congenital heart surgery between 7/2008 and 1/2018 and received a subsequent videofluoroscopic swallow study (VFSS). Demographic information, Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) category of each surgery, vocal fold mobility status, and VFSS findings were collected and analyzed.

RESULTS

Three hundred and seventy-four patients were included in the study. Fifty-four percent of patients were male, 24% were premature, and the average age at the time of VFSS was 59 days. Sixty percent of patients had oral dysphagia and 64% of patients had pharyngeal dysphagia. Fifty-one percent of patients had laryngeal penetration and 45% had tracheal aspiration. Seventy-three percent of these aspirations were silent. There was no association between surgical complexity, as defined by the STAT category, and dysphagia or airway protection findings. Patients with VFMI after surgery were more likely to have silent aspiration (odds ratio = 1.94, P < .01), even when adjusting for other risk factors.

CONCLUSION

Infants who undergo congenital heart surgery are at high risk for VFMI and aspiration across all five STAT categories. This study demonstrates the high prevalence of silent aspiration in this population and the need for thorough postoperative swallow evaluation.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

Pediatric Vocal Fold Paresis and Paralysis: A Narrative Review

Importance

Vocal fold paralysis (VFP) results from the disruption of neural motor outputs to laryngeal muscles. Children with VFP manifest various degrees of difficulties in phonation, breathing, and swallowing. Although the etiologic characteristics and symptoms of VFP are well established in adults, corresponding clinical profiles are notably different in children. Clinical management of VFP is particularly challenging in children because their larynges are still actively developing and the recovery of disrupted laryngeal nerves is often unpredictable. This review discusses the neurologic conditions and diagnostic and treatment considerations in pediatric VFP.

Observations

Injury to the peripheral laryngeal nerves and certain central nervous system diseases, such as Arnold-Chiari malformation type II, can result in VFP in infants and children. The incidence of unilateral vs bilateral VFP is variable across pediatric studies. Most reported VFP cases are associated with injury of the recurrent laryngeal nerve. Laryngeal electromyography requires needle insertion that must be performed under anesthesia with special care in the pediatric setting. Neither normative values nor standardized procedures of laryngeal electromyography are currently established for the pediatric population. Laryngeal reinnervation, endoscopic arytenoid abduction lateropexy, and laryngeal pacing are plausible treatment options for pediatric VFP. Despite these new advances in the field, no corresponding efficacy data are available for clinicians to discern which type of patients would be the best candidates for these procedures.

Conclusions and Relevance

The neuroanatomy and neurophysiology of VFP remain more elusive for the pediatric population than for adults. Basic and clinical research is warranted to fully comprehend the complexity of this laryngeal movement disorder and to better inform and standardize clinical practice.

The value of 1.5T MRI in the evaluation of vocal fold mobility in patients with goiter

The laryngoscopic examination remains the gold standard in the perioperative evaluation of the mobility of the vocal folds in patients with goiter. During the COVID-19 pandemic, many medical procedures, including laryngoscopy are optimized in terms of epidemiological safety. Therefore, it seems deeply justified to implement methods like i.e. ultrasound or MRI which can provide the diagnostic information usually obtained via laryngoscopic examination.

Aim of the study

To determine the value of dynamic MRI examination in the 1.5 T field in the assessment of the mobility of vocal folds in patients with goiter compared to healthy people and in relation to ultrasound examinations and routine laryngoscopy.

Materials and methods

35 healthy volunteers and 44 patients with goiter were subjected to videolaryngoscopy, dynamic examinations of the vocal folds during respiration and phonation using ultrasound and the MRI sequences: generic gradient echo (GRE) and true fast imaging with steady-state precession (TRUFI). The qualitative and quantitative data were analyzed, i.e. the angles of deviation from the midline of the vocal folds and the area of the right and left rima glottidis compartments.

Results

No statistically significant differences were found between the groups of healthy volunteers and patients with goiter in the values of the angles of deviation of the vocal folds with the use of ultrasound and two MRI dynamic sequences - GRE and TRUFI. There were also no statistically significant differences in the areas of the rima glottidis compartments between these two groups with the use of two MRI dynamic sequences - GRE and TRUFI. Among the analyzed parameters, the maximum size of each rima glottidis compartment was the only one to show features of sexual dimorphism and was significantly higher in men (GRE p < 0.001 and TRUFI p = 0.001). There was no correlation between the size of the minimum and maximum rima glottidis compartment and the total volume of the thyroid lobes in patients with goiter for the GRE and TRUFI sequences.

Conclusions

MRI is a promising tool for the objective assessment of the mobility of the vocal folds in patients with goiter, as well as for the qualification for treatment and monitoring its effects. It is particularly important during an epidemiological emergency due to its safety compared to laryngoscopy. The presence of the goiter and its volume do not limit the possibility of performing dynamic imaging studies of the vocal folds and do not affect the surface area of the glottis.

Transcutaneous ultrasound: An adjunct way to evaluate the intra-false vocal cord pathology-learning from a case of laryngeal Rosai-Dorfman disease

In clinical practice, it is sometimes difficult to evaluate the intra-false vocal fold lesion. Transcutaneous ultrasound can be an option to evaluate the soft tissue lesion within the right false vocal cord in a 65-year-old man with laryngeal Rosai-Dorfman disease presenting with hoarseness and right false cord swelling.

Pediatric Unilateral Vocal Fold Immobility

Vocal fold immobility in children can affect breathing, swallowing, and speech function. Although sometimes idiopathic, it is often caused by injury to the recurrent laryngeal nerve during cardiac surgery. A detailed history and physical examination can identify risk factors, which affect the rate of resolution and overall prognosis. Fiberoptic laryngoscopy can be used to confirm the diagnosis and evaluate laryngeal anatomy. Many treatment options exist to improve function and quality of life, including vocal fold injection and laryngeal innervation. [Pediatr Ann. 2021;50(7):e286-e291.].

Learning to Interpret Pediatric Vocal Fold Mobility: A Laryngeal Ultrasound Training Module

OBJECTIVES/HYPOTHESIS

Vocal fold movement impairment (VFMI) in infants and children is most commonly evaluated by flexible nasolaryngoscopy (FNL). FNL in this population can be challenging due to movement, floppy supraglottic structures, or secretions. Laryngeal ultrasound (LUS) may be an alternative, less invasive means of evaluating VFMI that also decreases aerosolization during the COVID-19 pandemic. The primary objective was to examine LUS interpretation proficiency for VFMI via an educational module. A secondary outcome was to determine whether quantitative measurements increase interpretation accuracy.

STUDY DESIGN

Prospective cohort trial.

METHODS

Medical students, residents, fellows, faculty, and staff were recruited to complete the module, composed of a 13-minute teaching video followed by 20 cases. Participants determined both qualitatively (subjective assessment) and then quantitatively (through protractor measurements of the vocal fold to arytenoid angle) whether there was normal versus impaired vocal fold mobility.

RESULTS

Thirty participants completed the LUS training module, and about one-third were otolaryngology residents. On average, each participant correctly identified 18 cases. The mean rank percent correct for quantitative measurements was significantly higher than that of qualitative interpretations (P < .0001). Measurements significantly caused participants to change their answer correctly compared to incorrectly (P < .0001). As the module progressed, there was no significant trend of more correct interpretations (P = .30). The sensitivity was higher for quantitative interpretations (89.0% vs. 87.3%) but specificity remained unchanged (92.6%).

CONCLUSION

Quantitative measurements may increase LUS interpretation accuracy. There was not a specific number of cases interpreted to achieve learning proficiency. LUS is an easily learned method to evaluate for VFMI across all training levels.

LEVEL OF EVIDENCE

3 (local cohort study nonrandomized) Laryngoscope, 2021.

Consensus statement by the American Association of Clinical Endocrinology (AACE) and the American Head and Neck Society Endocrine Surgery Section (AHNS-ES) on Pediatric Benign and Malignant Thyroid Surgery

OBJECTIVES

To provide a clinical disease state review of recent relevant literature and to generate expert consensus statements regarding the breadth of pediatric thyroid cancer diagnosis and care, with an emphasis on thyroid surgery. To generate expert statements to educate pediatric practitioners on the state-of-the-art practices and the value of surgical experience in the management of this unusual and challenging disease in children.

METHODS

A literature search was conducted and statements were constructed and subjected to a modified Delphi process to measure the consensus of the expert author panel. The wording of statements, voting tabulation, and statistical analysis were overseen by a Delphi expert (J.J.S.).

RESULTS

Twenty-five consensus statements were created and subjected to a modified Delphi analysis to measure the strength of consensus of the expert author panel. All statements reached a level of consensus, and the majority of statements reached the highest level of consensus.

CONCLUSION

Pediatric thyroid cancer has many unique nuances, such as bulky cervical adenopathy on presentation, an increased incidence of diffuse sclerosing variant, and a longer potential lifespan to endure potential complications from treatment. Complications can be a burden to parents and patients alike. We suggest that optimal outcomes and decreased morbidity will come from the use of advanced imaging, diagnostic testing, and neural monitoring of patients treated at high-volume centers by high-volume surgeons.

Consensus Statement by the American Association of Clinical Endocrinology (AACE) and the American Head and Neck Society Endocrine Surgery Section (AHNS) on Pediatric Benign and Malignant Thyroid Surgery

OBJECTIVES

To provide a clinical disease state review of recent relevant literature and to generate expert consensus statements regarding the breadth of pediatric thyroid cancer diagnosis and care, with an emphasis on thyroid surgery. To generate expert statements to educate pediatric practitioners on the state-of-the-art practices and the value of surgical experience in the management of this unusual and challenging disease in children.

METHODS

A literature search was conducted and statements were constructed and subjected to a modified Delphi process to measure the consensus of the expert author panel. The wording of statements, voting tabulation, and statistical analysis were overseen by a Delphi expert (J.J.S.).

RESULTS

Twenty-five consensus statements were created and subjected to a modified Delphi analysis to measure the strength of consensus of the expert author panel. All statements reached a level of consensus, and the majority of statements reached the highest level of consensus.

CONCLUSION

Pediatric thyroid cancer has many unique nuances, such as bulky cervical adenopathy on presentation, an increased incidence of diffuse sclerosing variant, and a longer potential lifespan to endure potential complications from treatment. Complications can be a burden to parents and patients alike. We suggest that optimal outcomes and decreased morbidity will come from the use of advanced imaging, diagnostic testing, and neural monitoring of patients treated at high-volume centers by high-volume surgeons.

Application of Transcutaneous Laryngeal Ultrasonography in the Diagnosis of Vocal Fold Polyps

The aim of this study was to explore the value of transcutaneous laryngeal ultrasonography in the diagnosis of vocal fold polyps. From December 2016 to June 2019, 87 patients with vocal fold polyps diagnosed pathologically in the Otolaryngology Head and Neck Surgery Department of the Second Affiliated Hospital of Xi'an Jiaotong University were enrolled and examined by electronic laryngoscopy and percutaneous laryngeal ultrasound on the same day before operation. To observe the effect of calcification length as a percentage of thyroid cartilage at the glottic level on vocal fold display, the characteristics of ultrasound images of vocal fold polyps and the value of transcutaneous laryngeal ultrasonography in the diagnosis of vocal fold polyps were assessed. Among 87 patients, the calcification rate of thyroid cartilage at the glottic level was 33.3%. The differences in calcification rate and percentage of calcification length between males and females were statistically significant. The rate of detection of vocal folds decreased gradually with an increase in calcification length percentage. Imaging features of vocal fold polyps were hypo-echoic with a clear boundary and regular shape. The detection rates for circular and non-circular polyps were 92.0% and 70.6%. Ultrasound was more likely to detect circular than non-circular polyps; however, the difference was not significant. Transcutaneous laryngeal ultrasonography can identify the morphology and location of vocal fold polyps and is non-invasive and highly accurate. Therefore, it has the potential to be an effective supplement to laryngoscopy for initial screening and post-operative review of vocal fold polyps.

Recorded Flexible Nasolaryngoscopy for Neonatal Vocal Cord Assessment in a Prospective Cohort

OBJECTIVE

Assessing vocal cord mobility by flexible nasolaryngoscopy (FNL) can be difficult in neonates. To date, prospective studies evaluating the incidence and diagnostic accuracy of vocal cord paralysis (VCP) after surgical patent ductus arteriosus (PDA) ligation are limited. It is unknown whether video FNL improves diagnosis in this population. This study compared video recordings with bedside evaluation for diagnosis of VCP and determined inter-rater reliability of the diagnosis of VCP in preterm infants after PDA ligation.

METHODS

Prospective cohort of preterm neonates undergoing bedside FNL within two weeks of extubation following PDA ligation. In a subset, FNL was recorded. Two pediatric otolaryngologists, blinded to the initial diagnosis, reviewed the FNL video recordings.

RESULTS

Eighty infants were enrolled and 37 with a recorded FNL were included in the cohort. Average gestational age at birth was 25.2 weeks (SD: 1.2) and postmenstrual age at FNL was 37.0 weeks (SD: 4.5), which was 9.5 days (SD: 14.7) after extubation following PDA repair. There were 6 diagnosed with left VCP (16.2%; 95% CI: 4.3-28.1%) at bedside, and 9 diagnosed by video review (24.3%; 95% CI: 10.5-38.1%) (P = .56). Videos confirmed all 6 VCP diagnosed initially, but also identified 3 additional cases. Though imperfect, reviewing FNL by video showed substantial reliability (kappa = .75), with 91.9% agreement.

CONCLUSION

Video recorded FNL most often confirms a bedside diagnosis of VCP, but may also identify discrepancies. Physicians should consider the limitations of diagnosis especially when infants persist with symptoms such as weak voice or signs of postoperative aspiration.

LEVEL OF EVIDENCE

2b.

Speech-Language Pathology Guidance for Tracheostomy During the COVID-19 Pandemic: An International Multidisciplinary Perspective

Purpose As the COVID-19 pandemic has unfolded, there has been growing recognition of risks to frontline health care workers. When caring for patients with tracheostomy, speech-language pathologists have significant exposure to mucosal surfaces, secretions, and aerosols that may harbor the SARS-CoV-2 virus. This tutorial provides guidance on practices for safely performing patient evaluation and procedures, thereby reducing risk of infection. Method Data were collated through review of literature, guidelines, and consensus statements relating to COVID-19 and similar high-consequent infections, with a focus on mitigating risk of transmission to health care workers. Particular emphasis was placed on speech-language pathologists, nurses, and other allied health professionals. A multinational interdisciplinary team then analyzed findings, arriving at recommendations through consensus via electronic communications and video conference. Results Reports of transmission of infection to health care workers in the current COVID-19 pandemic and previous outbreaks substantiate the need for safe practices. Many procedures routinely performed by speech-language pathologists have a significant risk of infection due to aerosol generation. COVID-19 testing can inform level of protective equipment, and meticulous hygiene can stem spread of nosocomial infection. Modifications to standard clinical practice in tracheostomy are often required. Personal protective equipment, including either powered air-purifying respirator or N95 mask, gloves, goggles, and gown, are needed when performing aerosol-generating procedures in patients with known or suspected COVID-19 infection. Conclusions Speech-language pathologists are often called on to assist in the care of patients with tracheostomy and known or suspected COVID-19 infection. Appropriate care of these patients is predicated on maintaining the health and safety of the health care team. Careful adherence to best practices can significantly reduce risk of infectious transmission.

Comparison of Endoscopic and Ultrasonographic Measurements of the Subglottic Airway in Children

OBJECTIVE

To compare measurements of the pediatric subglottis obtained by surgeon-performed ultrasound and endoscopy.

STUDY DESIGN

Prospective observational comparison-of-methods study.

SETTING

Tertiary care pediatric hospital.

SUBJECTS AND METHODS

Thirty-one patients who underwent direct laryngoscopy from May 2017 to July 2018 were recruited. Transcervical ultrasound was used to visualize the vocal folds, subglottis, and cervical trachea. The anterior-posterior (AP) and transverse (TV) diameter of the subglottic space were measured endoscopically and via ultrasound by 2 independent evaluators. Measurements were compared for correlation, bias, and agreement. A clinically acceptable bias for subglottic diameter was assumed to be 0.5 mm or less.

RESULTS

The median age of enrolled patients was 2.6 years (range, 4 months-13.3 years). Endoscopic subglottic AP and TV measurements ranged from 3.33 mm to 14.81 mm and from 4.44 mm to 11.65 mm, respectively, while ultrasonographic AP and TV measurements ranged from 4.57 mm to 9.85 mm and from 3.77 mm to 8.96 mm. Pearson coefficient showed strong a correlation for both endoscopic and ultrasound AP (R = 0.8081, P < .0001) and TV (R = 0.8796, P < .001) measurements of the subglottis. Bland-Altman plots revealed a bias (average discrepancy) for AP measurements of 0.22 mm and 0.11 mm for TV measurements.

CONCLUSION

Endoscopic and ultrasonography measurements of the pediatric subglottic airway were strongly correlated. The discrepancy between AP and TV measurements was less than 0.5 mm. Ultrasound of the subglottis may be an alternative to endoscopic assessment of the airway for measurement of the subglottic airway in children in select cases.

Neonatal Vocal Fold Paralysis

Vocal fold paralysis (VFP) is an important cause of respiratory and feeding compromise in infants. The causes of neonatal VFP are varied and include central nervous system disorders, birth-related trauma, mediastinal masses, iatrogenic injuries, and idiopathic cases. Bilateral VFP often presents with stridor or respiratory distress and can require rapid intervention to stabilize an adequate airway. Unilateral VFP presents more subtly with a weak cry, swallowing dysfunction, and less frequently respiratory distress. The etiology and type of VFP is important for management. Evaluation involves direct visualization of the vocal folds, with additional imaging and testing in select cases. Swallowing dysfunction, also known as dysphagia, is very common in infants with VFP. A clinical assessment of swallowing function is necessary in all cases of VFP, with some patients also requiring an instrumental swallow assessment. Modification of feeding techniques and enteral access for feedings may be necessary. Airway management can vary from close monitoring to noninvasive ventilation, tracheostomy, and laryngeal surgery. Long-term follow-up with otolaryngology and speech-language pathology service is necessary for all children with VFP to ensure adequate breathing, swallowing, and phonation. The short- and long-term health and quality-of-life consequences of VFP can be substantial, especially if not managed early.

Point of care, clinician-performed laryngeal ultrasound and pediatric vocal fold movement impairment

INTRODUCTION

Vocal fold movement impairment (VFMI) is a well-known sequela of cervical and thoracic procedures performed in the vicinity of the recurrent laryngeal nerve. Interpretation of flexible nasolaryngoscopy (FNL) can be difficult in young children due to crying, secretions, and obstructing supraglottic structures. We have previously published on the use of radiologist performed and interpreted, laryngeal ultrasound (LUS) to evaluate vocal fold mobility with substantial agreement with FNL in infants in the cardiovascular intensive care unit. The purpose of this study was to evaluate point of care, clinician performed, LUS for vocal fold mobility in a pediatric voice clinic.

METHODS

LUS and FNL were performed and recorded on 30 consecutive patients (11 with a clinical diagnosis of VFMI and 19 with clinically normal mobility) in a pediatric voice clinic. All LUS was performed by a single clinician (reviewer 1) with a GE logiq P9 and 12 MHz linear probe. Deidentified recordings of the LUS and FNL (without sound) were reviewed in random order by 2 fellowship trained pediatric otolaryngologists who were blinded to the vocal fold mobility. Cohen's kappa was used to determine agreement.

RESULTS

There was substantial agreement (κ  = 0.7) between the reviewers regarding interpretation of LUS as well as regarding interpretation of FNL κ  = 0.7802. In addition, each reviewer had near perfect to substantial agreement between their interpretation of the LUS and FNL (reviewer 1 κ  = 0.9294 and reviewer 2 κ  = 0.8413).

CONCLUSION

Point of care, clinician performed, LUS can be used for the identification of VFMI with substantial agreement with FNL with good inter-rater reliability. This provides clinicians with another tool in their armamentarium for the evaluation of challenging larynges.

Imaging of Airway Obstruction in Children

Various imaging techniques may be used to diagnose airway obstruction in children. Digital radiography, computed tomography and magnetic resonance imaging are the most important modalities, but the choice of technique will depend on the level and nature of suspected obstruction, as well as patient-specific factors such as age and ability to cooperate. This review examines the forms of airway obstruction that are commonly encountered in childhood.

Application-Based Translaryngeal Ultrasound for the Assessment of Vocal Fold Mobility in Children

Objective

To compare the evaluation of vocal fold mobility between flexible nasal laryngoscopy (FNL) and a handheld application-based translaryngeal ultrasound (TLUS) platform.

Study Design

Prospective analysis included patients with unknown vocal fold mobility status who underwent FNL and TLUS.

Setting

Tertiary referral center.

Subjects and Methods

TLUS was performed on 23 consecutive children (<18 years old) presenting for laryngoscopy due to unknown vocal fold mobility status. After the recording of three 10-second TLUS videos as well as FNL, the study was divided into 2 parts: parental assessment of laryngeal ultrasound at the time of patient evaluation and random practitioner assessment of ultrasound videos.

Results

We describe 23 patients who underwent TLUS and FNL. Ten patients (43.5%) had normal vocal fold function bilaterally, and 13 (56.5%) had either left or right vocal fold immobility. Family members and physicians correctly identified the presence and laterality of impaired vocal fold mobility in 22 of 23 cases (κ = 0.96). The sensitivity, specificity, positive predictive value, and negative predictive value of FLUS in diagnosing vocal fold immobility were 92.3%, 100%, 100%, and 90.9%, respectively. Random practitioners accurately identified the presence and laterality of vocal fold immobility under all circumstances.

Conclusion

A handheld application-based ultrasound platform is both sensitive and specific in its ability to identify vocal fold motion impairment. Portable handheld TLUS has the potential to serve as a validated screening examination, even by inexperienced providers, and in specific cases may obviate the need for an invasive transnasal laryngoscopy.