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Farrell A, Raol N. Current opinion in otolaryngology and head and neck surgery: the role of the otolaryngologist in the management of pediatric dysphagia. Curr Opin Otolaryngol Head Neck Surg 2023; 31:412-418. [PMID: 37820272 DOI: 10.1097/moo.0000000000000934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
PURPOSE OF REVIEW Dysphagia affects at least 1% of the pediatric population. This prevalence further increases in patients who are born prematurely or who have underlying neuromuscular or cardiopulmonary disorders. A multidisciplinary team approach, including an Otolaryngologist, can help promote an expedited diagnosis and therapeutic regimen, ensuring that the patient receives adequate nutrition needed for growth and development. RECENT FINDINGS The development and growth of multidisciplinary aerodigestive clinics have improved outcomes in pediatric patients with dysphagia. If a structural concern is noted on examination, there remain a multitude of medical and surgical options to help improve patient outcomes and swallow. These treatment options are usually multimodality and specific interventions may be employed to target a specific and notable abnormality. SUMMARY Pediatric dysphagia is a complex concern. For the otolaryngologist, etiologies with surgical targets may include ankyloglossia, tonsillar hypertrophy, laryngomalacia, laryngo-esophageal cleft, vocal fold movement impairment, and cricopharyngeal achalasia. The development and formalization of a multidisciplinary approach has streamlined and broadened treatment options for these patients. An otolaryngologist is integral as part of the treatment team of these patients.
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Affiliation(s)
- Annie Farrell
- Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine
| | - Nikhila Raol
- Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine
- Division of Pediatric Otolaryngology, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
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Jáuregui EJ, Abts MF, Dahl JP, Parikh SR, Horn DL, Pickens M, Park JS, DeMarre K, Hoang J, Johnson K. Beyond Laryngeal Clefts: Interarytenoid Injection Augmentation to Predict Success of Suture Augmentation in Children. Laryngoscope 2022. [PMID: 36069277 DOI: 10.1002/lary.30374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 07/26/2022] [Accepted: 08/09/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To assess the efficacy of interarytenoid injection augmentation (IAIA) and the ability of IAIA to predict response to interarytenoid suture augmentation (IASA) based on diet advancement on video fluoroscopic swallow studies (VFSS). METHODS Retrospective cohort analysis of patients with persistent pharyngeal dysphagia at a tertiary children's hospital with VFSS pre- and post-IAIA were included between March 2011 and June 2019. RESULTS Median age of the 229 patients was 2.2 years (5.8 months-19 years). Interarytenoid mucosal height (IAMH) was found to be above the false vocal folds in 112 patients (53.4%) and at true vocal folds in 10 (4.9%) patients. On VFSS post-IAIA, 95 (41.5%) patients were successfully advanced in recommended diet consistency, 115 (50.2%) were stable, and 19 (8.3%) needed thicker consistency. Paired t-tests on pre- and post-operative consistency scores showed significant improvement, p-value of <0.0001, 95% confidence interval (CI; 0.50-0.85). Poisson regression found no covariates with significant association with improvement on IAIA. For IASA patients, 35/60 (58.3%) improved on post-op VFSS. Paired t-tests on pre- and post-operative consistency scores showed significant improvement, p-value of <0.0001, 95% CI (0.63-1.33). Positive predictive value for IAIA predicting response to IASA was 77% with positive likelihood ratio of 2.3. The response to IAIA versus no response to IAIA likelihood ratios were found to have a statistically significant difference (p < 0.05). CONCLUSIONS Our study suggests IAIA yields objective improvement in swallow function on VFSS in nearly half of our patients and may be a reliable diagnostic tool to predict response to IASA in patients with persistent pharyngeal dysphagia with or without a laryngeal cleft. LEVEL OF EVIDENCE Level 3 Laryngoscope, 2022.
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Affiliation(s)
- Emmanuel J Jáuregui
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, U.S.A
| | - Matthew F Abts
- Division of Pulmonary and Sleep Medicine, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - John P Dahl
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, U.S.A.,Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Sanjay R Parikh
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, U.S.A.,Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - David L Horn
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, U.S.A.,Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Michael Pickens
- Division of Gastroenterology and Hepatology, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Jason S Park
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University, Nashville, Tennessee, U.S.A
| | - Kim DeMarre
- Speech and Language Services, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Jennifer Hoang
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, U.S.A
| | - Kaalan Johnson
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, U.S.A.,Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A
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Weinstock MS, McCoy JL, Cangilla K, Shaffer AD, Maguire RC, Tobey ABJ, Simons JP, Padia RK. Predictive Utility of the Penetration-Aspiration Scale in Inter-Arytenoid Injection Augmentation. Laryngoscope 2020; 131:E1707-E1713. [PMID: 33009827 DOI: 10.1002/lary.29142] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 09/08/2020] [Accepted: 09/13/2020] [Indexed: 11/07/2022]
Abstract
OBJECTIVES/HYPOTHESIS To determine the utility of preoperative penetration-aspiration scale (PAS) scores and clinical findings on modified barium swallow (MBS) in predicting advancement of diet after interarytenoid injection augmentation (IAIA). STUDY DESIGN Retrospective review. METHODS In this retrospective cohort study, 372 consecutive patients who underwent IAIA for pharyngeal dysphagia between 2009 and 2019 were initially identified. Patients were excluded from the study if they had insufficient preop MBS, no postop MBS within 3 months of injection, supraglottoplasty, or underlying neurological condition. Ninety-three patients were included in the study. Pre- and postoperative PAS scores were recorded, as were pre and postop diets. PAS scores were calculated by a single pediatric speech and language pathologist. RESULTS Average PAS score on MBS was 5.87 (standard deviation [SD] 2.74); median (range) = 8 (1-8). Postop average was 4.29 (SD 3.02); median (range) = 2 (1-8), P < .001. Those with worse preop PAS scores had increased odds of improvement in diet (odds ratio 1.24, 95% confidence interval [CI] 1.02-1.49, P = .029). An improvement in PAS score of 3.0 or greater predicted an improvement in diet with a sensitivity of 76.7% and a specificity of 85.7%. CONCLUSIONS PAS score on MBS can be a useful tool when assessing pediatric patients who may be candidates for IAIA. Prospectively comparing PAS score in patients post-IAIA to patients solely undergoing diet modification can help to better objectively assess differences in outcomes and understand the full utility of PAS score. LEVEL OF EVIDENCE Level III (Individual Cohort Study) Laryngoscope, 131:E1707-E1713, 2021.
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Affiliation(s)
- Michael S Weinstock
- Department of Otolaryngology, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
| | - Jennifer L McCoy
- Department of Otolaryngology, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
| | - Kristin Cangilla
- Department of Speech and Language Pathology, Feeding and Swallowing Center, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
| | - Amber D Shaffer
- Department of Otolaryngology, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
| | - Raymond C Maguire
- Department of Otolaryngology, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
| | - Allison B J Tobey
- Department of Otolaryngology, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
| | - Jeffrey P Simons
- Department of Otolaryngology, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
| | - Reema K Padia
- Department of Otolaryngology, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
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Isaac A, Svystun O, Johannsen W, El-Hakim H. Injection augmentation and endoscopic repair of type 1 laryngeal clefts: development of a management algorithm. J Otolaryngol Head Neck Surg 2020; 49:49. [PMID: 32664993 PMCID: PMC7362509 DOI: 10.1186/s40463-020-00447-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 07/06/2020] [Indexed: 12/16/2022] Open
Abstract
Objectives To describe indications for injection augmentation (IA), endoscopic repair (ER) and conservative methods for the management of type 1 laryngeal cleft (LC1) and propose a management algorithm. We also aimed to compare success of IA and ER and determine independent predictors of treatment failure. Methods Retrospective study of patients diagnosed with LC1 at a Pediatric Otolaryngology referral centre between 2004 and 2016. All had pre-operative instrumental swallowing evaluation (VFSS/FEES), and were managed with a combination of conservative measures, IA and/or ER. We collected demographics, symptoms, comorbidities, VFSS/FEES results, and operative details. The primary outcome was symptom resolution by parental report. The secondary outcome was predictors of treatment failure. Results 88 patients were included in the analysis, with mean age 26 ± 25 months. Most presented with choking events (68%) or recurrent pneumonias (48%). In total, there were 55 IA performed and 45 ER. Of the patients who received IA, 19 required subsequent ER. 95% had symptom improvement, 67% had complete resolution. IA had a 56% long-term success rate, whereas that for ER was 85%. Tube feeding at initial evaluation was an independent predictor of treatment failure (HR 11.33 [1.51–84.97], p = 0.018). Conclusions LC1 can be effectively managed with a combination of IA and ER with favorable results. Failure to respond to IA does not preclude ER, and both have their role in management. Patients who are tube fed have a higher probability of treatment failure. We propose a management algorithm that includes reasoning for conservative approaches, and reduces exposure to general anesthesia.
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Affiliation(s)
- Andre Isaac
- Pediatric Otolaryngology, Division of Otolaryngology Head & Neck Surgery, Departments of Surgery & Pediatrics, The Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada.
| | - Orysya Svystun
- Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Wendy Johannsen
- Pediatric Otolaryngology, Division of Otolaryngology Head & Neck Surgery, Departments of Surgery & Pediatrics, The Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada.,Outpatient Feeding & Swallowing Service, The Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Hamdy El-Hakim
- Pediatric Otolaryngology, Division of Otolaryngology Head & Neck Surgery, Departments of Surgery & Pediatrics, The Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada.,Outpatient Feeding & Swallowing Service, The Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
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