Voice problems after pediatric laryngotracheal reconstruction: videolaryngostroboscopic, acoustic, and perceptual assessment

A Single Center Description of Adult and Pediatric Endoscopic Posterior Costal Cartilage Grafting

OBJECTIVE

Posterior glottis impairment alters breathing, voicing, and swallowing. Bilateral vocal fold movement impairment (BVFMI) occurs when the vocal cords are fixed/remain midline. Studies inadequately assessed endoscopic posterior costal cartilage grafting (enPCCG) for BVFMI across broad ages. We aim to assess decannulation and prosthesis free airway in children and adults who have undergone enPCCG.

STUDY DESIGN

Retrospective cohort.

SETTING

Referral center.

METHODS

This study included adults and children who received enPCCG for BVFMI (2010-2018) and were followed for 35 months on average. The main outcome was successful decannulation of patients, or airway improvement in those without tracheostomy. Data on comorbidities, surgical complications, and interventions following surgery were collected.

RESULTS

Ten children and 11 adults underwent enPCCG for BVFMI. Eighty-one percent of patients had a tracheostomy at surgery; adults were more likely to have a tracheostomy at surgery (P = 0.035), and to undergo double-staged procedure (P = 0.035) and stent (P = 0.008). Average stent duration was 29.7 days. Overall decannulation rate was 76% (90% for children; 70% for adults). Children were more likely to receive postoperative intensive care unit care (P = 0.004). Adults had mean 4.4 post-enPCCG interventions per patient compared to children's mean 3.91 interventions. The most common interventions were steroid injection (17.6%) and balloon dilation (16%). Preliminary analysis suggests postoperative dysphonia was reported in 66.7% of patients; postoperative dysphagia was rare.

CONCLUSION

EnPCCG was more successful at achieving decannulation in children. Adults required additional interventions. A double-staged operation with prolonged stenting is recommended for adult patients. A majority of patients were decannulated at last follow-up.

Effects of Vibratory Source on Auditory-Perceptual and Bio-Inspired Computational Measures of Pediatric Voice Quality

OBJECTIVE

The vibratory source for voicing in children with dysphonia is classified into three categories including a glottal vibratory source (GVS) observed in those with vocal lesions or hyperfunction; supraglottal vibratory sources (SGVS) observed secondary to laryngeal airway injuries, malformations, or reconstruction surgeries; and a combination of both glottal and supraglottal vibratory sources called mixed vibratory source (MVS). This study evaluated the effects of vibratory source on three primary dimensions of voice quality (breathiness, roughness, and strain) in children with GVS, SGVS, and MVS using single-variable matching tasks and computational measures obtained from bio-inspired auditory models.

METHODS

A total of 44 dysphonic voice samples from children aged 4-11 years were selected. Seven listeners rated breathiness, roughness, and strain of 1000-ms /ɑ/ samples using single-variable matching tasks. Computational estimates of pitch strength, amplitude modulation filterbank output, and sharpness were obtained through custom-designed MATLAB algorithms.

RESULTS

Perceived roughness and strain were significantly higher in children with SGVS and MVS compared to children with GVS. Among the computational measures, only the modulation filterbank output resulted in significant differences among vibratory sources; a posthoc test revealed that children with SGVS had greater amplitude modulation than children with GVS, as expected from their rougher voice quality.

CONCLUSIONS

The results indicate that the output of an auditory amplitude modulation filterbank model may capture characteristics of SGVS that are strongly related to the rough voice quality.

Vocal Fold Injection Augmentation for Post-Airway Reconstruction Dysphonia: A Case Series

OBJECTIVES

Post airway reconstruction dysphonia (PARD) is common and has a significant effect on the quality of life of patients. Vocal fold injection augmentation (VFIA) is one treatment that can be used to improve glottic insufficiency in some patients. The goal of this study was to characterize the use and outcomes of VFIA for PARD.

METHODS

Retrospective chart review from January 2007 to July 2018 at a tertiary pediatric care center. Consecutive patients with PARD who underwent VFIA, who had a preoperative voice evaluation and a follow-up evaluation within 3 months after VFIA (fat, carboxymethylcellulose gel, hyaluronic acid).

RESULTS

Thirty-four patients (20 female) underwent VFIA. The mean age at the time of the injection was 13.6 years (SD 6.1). Twenty patients (58.8%) had a history of prematurity and a mean of 1.8 open airway surgeries. After injection, 29/34 patients (85.3%) noted a subjective voice improvement. The baseline Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) overall severity score decreased by a mean of 5.7 (SD = 19.6) points, P = .12. Total pediatric Voice Handicap Index (pVHI) improved by 6.0 (SD = 19.5) points, from 57.4 (SD = 20.0) to 51.4 (SD = 17.2), P = .09. Functional pVHI subscore demonstrated a significant improvement, with a decrease of 3.4 (SD = 7.3) points, P = .02. All procedures were performed as an overnight observation and no complication occurred.

CONCLUSION

Patients with PARD represent a complex subset of patients. VFIA is a straightforward intervention that may improve voice perception. Many patients reported subjective improvement despite minimal objective measurement. Further work is warranted to elucidate the role of injection in management of PARD.

Preliminary Assessment of Dynamic Voice CT in Post–Airway Reconstruction Patients

Objectives

To compare the ability of the dynamic voice computed tomography (CT) scan to characterize laryngeal function in airway reconstruction patients vs bedside endoscopic nasopharyngolaryngoscopy and videolaryngostroboscopy.

Study Design

Case series with chart review.

Settings

Pediatric tertiary care center.

Subjects and Methods

Retrospective case series of children and young adults with a history of complex airway surgeries with subsequent dysphonia. We analyzed clinical data for all patients who underwent an airway reconstruction procedure between January 1, 2010, and April 30, 2016, and also had a dynamic voice CT and bedside endoscopic exam during the same period.

Results

Twenty-four patients were analyzed (4 male, 20 female) with a mean age of 15.1 years (95% confidence interval [CI], 12.9-17.22). Patients had a mean of 2.2 airway surgeries (95% CI, 1.8-2.6), with 62.5% of them being open procedures. Laryngotracheoplasty with a cartilage graft was the most common procedure (40.0%). The pattern of laryngeal closure could be detected in all cases with the dynamic CT scan (n = 24/24, 100%) compared to 87.5% (21/24) with the standard endoscopic examination ( P = .04). The location of gap closure could be detected in all cases (24/24) with the dynamic voice CT while 20.8% (5/24 patients) could not be rated with standard endoscopy/stroboscopy ( P = .02). Dynamic voice CT was able to assess the vertical closure pattern of the glottis 100% (24/24) while it could be detected in 83.3% (20/24) cases with endoscopic study ( P = .04).

Conclusion

Dynamic voice CT shows promise as an additional tool for evaluation of patients with a history of complex airway procedures by providing complementary information.

Evaluation of Dyspnea Outcomes After Endoscopic Airway Surgery for Laryngotracheal Stenosis

Importance

Endoscopic airway surgery is a frequently used procedure in the management of laryngotracheal stenosis (LTS); however, no established outcome measures are available to assess treatment response.

Objective

To assess acoustics and aerodynamic measures and voice- and dyspnea-related quality of life (QOL) in adult patients with LTS who undergo endoscopic airway surgery.

Design, Setting, and Participants

This case series compared preoperative measures and postoperative outcomes among adult patients who underwent endoscopic airway surgery for LTS from September 1, 2013, to September 30, 2015, at the tertiary care Johns Hopkins Voice Center. Patients were excluded if they did not undergo balloon dilation or if they had multilevel or glottic stenosis. The Phonatory Aerodynamic System was used to quantify laryngotracheal aerodynamic changes after surgery. Final follow-up was completed 2 to 6 weeks after surgery.

Main Outcomes and Measures

The voice-related QOL instrument (V-RQOL), Dyspnea Index, and Clinical Chronic Obstructive Pulmonary Disease Questionnaire were completed before and after endoscopic surgery. Consensus auditory perceptual evaluation of voice, acoustic measurements, and aerodynamic outcomes were also assessed.

Results

Fourteen patients (1 man and 13 women; mean [SD] age, 45.4 [4.3] years) were enrolled. The mean postoperative V-RQOL scores (n = 14) increased from 74.3 to 85.5 (mean of difference, 11.3; 95% CI, 2.2 to 20.3). The mean postoperative Dyspnea Index (n = 14) decreased from 26.9 to 6.6 (mean of difference, -20.3; 95% CI, -27.9 to -12.7); the mean postoperative Clinical Chronic Obstructive Pulmonary Disease Questionnaire scores (n = 9) decreased from 3.2 to 1.0 (mean of difference, -2.2; 95% CI, -3.4 to -0.9). Postoperative mean vital capacity (n = 14) increased from 2.5 to 3.1 L (mean of difference, 0.6 L; 95% CI, 0.3-1.0 L), whereas mean laryngeal resistance (n = 14) decreased from 73.9 to 46.4 cm H2O/L/s (mean of difference, -27.5 cm H2O/L/s; 95% CI, -44.8 to -10.3 cm H2O/L/s) postoperatively.

Conclusions and Relevance

Patients demonstrate statistically and clinically significant improvement in dyspnea-related QOL, whereas a few patients showed a clinically significant improvement in V-RQOL. Dyspnea-related QOL outcomes should be added to airway surgeons' regular assessment of patients with LTS to measure treatment response and inform the decision to perform a second operation, whereas V-RQOL outcomes need additional prospective study with a larger sample size. The Phonatory Aerodynamic System is not an optimal method to quantify changes in laryngotracheal aerodynamics after intervention in LTS.

Comparison of Pediatric Voice Handicap Index Scores with Perceptual Voice Analysis in Patients following Airway Reconstruction

Objectives

We performed a retrospective review to compare a subjective parental proxy-derived voice handicap survey to an observer-derived method of measuring voice perturbation in children who have undergone airway reconstruction. The main outcome measures were the Pediatric Voice Handicap Index (pVHI) total score and the Overall Severity score on the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V).

Methods

The percent Overall Severity CAPE-V score (score divided by 100) and the percent pVHI score (score divided by 92) were calculated. A Wilcoxon signed rank test was used to compare CAPE-V scores with the pVHI total scores. The relationship between the pVHI scores and the CAPE-V scores was investigated with a Spearman correlation. Subgroup analysis was performed to determine the relationship of surgery type to CAPE-V and pVHI scores.

Results

Fifty subjects with a history of airway surgery who were evaluated between 2005 and 2008 were identified. Forty-two of the 50 subjects had complete data for review. Their median age was 7.1 years (range, 3.3 to 17.9 years). Their pVHI total scores had a median of 30 (range, 1 to 80). Their Overall Severity CAPE-V scores had a median of 50.5 (range, 0 to 98). Their median CAPE-V percent was higher than their median pVHI percent (50.5% versus 32.6%; p = 0.0003). A weak correlation was found between the Overall Severity CAPE-V score and the pVHI total score (rho = 0.41; p = 0.0003). There was a trend toward higher Overall Severity CAPE-V scores in patients who underwent cricotracheal resection. The total number of airway surgeries was significantly correlated with the Overall Severity CAPE-V score (rho = 0.6; p < 0.0001) but not with the pVHI score.

Conclusions

Children who undergo airway reconstruction often have a resulting voice disturbance that can affect their lives in multiple dimensions. The results of this study revealed a weak-to-fair correlation between the parent-reported pVHI total score and expert ratings of voice quality using the CAPE-V. In this patient population, both of these tools provided important information regarding the relationship of the severity of voice disturbance to its handicapping effects.

Characterization of Supraglottic Phonation in Children after Airway Reconstruction

Objectives

We examined select acoustic (signal type), aerodynamic, and perceptual measures and associated surgical data in a cohort of children who were endoscopically identified as using supraglottic phonation after undergoing airway reconstruction.

Methods

Twenty-one children (4 to 18 years of age) who were seen in the Cincinnati Children's Hospital Medical Center for Pediatric Voice Disorders and identified as using supraglottic phonation were included in this study. According to standard protocol, each of these children underwent acoustic, aerodynamic, and perceptual analyses and laryngeal imaging. Their medical records were reviewed for surgical history.

Results

Four primary supraglottic compression patterns and 3 distinct sound sources for voice were identified. Signal type classification revealed that 20 of 21 voice signals were either type II or type III. Signal type was moderately associated with compression pattern (p = 0.01). No statistically significant findings were found in testing the Consensus Auditory Perceptual Evaluation of Voice (CAPE-V) Overall Severity score against compression patterns and vibration source. The mean Strain scores for participants who used a combined source of vibration were significantly higher than for those who used their ventricular folds.

Conclusions

The compensatory compression patterns and alternate sources of vibration used by these children resulted in moderate to severe dysphonias. How children compensate after undergoing airway reconstruction has important implications for behavioral and surgical interventions aimed at improving voice quality. Not all aspects of traditional voice evaluation are suitable for this population.

Use of Conchal Cartilages for Laryngotracheal Stenosis: Experiences at a Tertiary Care Hospital of Eastern India

To describe the experience of anterior cricotracheal split with insertion of conchal cartilage graft in the treatment of subglottic and tracheal stenosis at a tertiary care hospital of eastern India. Six patients were included in the study, in the age group of 20-48 years. Out of which five patients were successfully decannulated after 3 months of laryngotracheal reconstruction with help of conchal cartilage. One case was undergone resection anastomosis after failure of the above technique. Successful restoration of the airway with decannulation in five cases and failure in one case. The subglottic and upper tracheal stenosis are successfully treated with anterior cricotracheal split and augmentation of the airway with conchal cartilage. It is a new technique of using conchal cartilage in the literature of laryngotracheal reconstruction.

Safety and postoperative adverse events in pediatric airway reconstruction: Analysis of ACS-NSQIP-P 30-day outcomes

OBJECTIVES

Prior research has shown that airway reconstructive procedures comprise significant composite morbidity compared to the whole of pediatric otolaryngologic cases evaluated in the American College of Surgeon's National Surgery Quality Improvement Program-Pediatric (ACS-NSQIP-P) platform. We describe postoperative sequelae of pediatric airway reconstructive procedures and identify predictive factors for adverse events.

METHODS

Current procedural terminology (CPT) codes were used to identify children undergoing included procedures in the 2012 to 2014 ACS-NSQIP-P public use files (PUF). Targeted variables included patient demographics and 30-day postoperative events (reoperation, readmission, and complications). Event rates were determined and compared within subgroups. Multivariate logistic regression was performed to identify predictive factors for major adverse events.

RESULTS

In 3 years of PUF data (183,283 total cases), 198 cases (0.11%) were airway reconstructive procedures. The most common was laryngoplasty (CPT 31580, 31582; n = 111, 56.1%), followed by cervical tracheoplasty (CPT 31750; n = 47, 23.7%), tracheal resection (CPT 31780; n = 24, 12.1%), and cricoid split (CPT 31587, n = 16, 8.1%). There were 131 premature children (66.2%) and 94 children (47.5%) with history of bronchopulmonary dysplasia. Thirty-day postoperative sequelae included readmissions (n = 42, 21.2%), complications (n = 27, 13.6%), and reoperations (n = 14, 7.1%). On univariate analysis, children less than 3 years of age were more likely to undergo an unplanned reoperation. There were no significant predictive factors for readmission or complication. On multivariate analysis, there was a trend toward higher rates of unplanned reoperations in children less than 3 years of age.

CONCLUSION

The 30-day adverse event rate in pediatric airway surgery is high, with no identifiable predictors noted in the analysis of these data. Findings imply that systematic collection of variables and outcomes specific to pediatric airway surgery, in addition to standard NSQIP workflow, will be essential for NSQIP-P to truly effect quality improvement in these high-risk procedures.

LEVEL OF EVIDENCE

4. Laryngoscope, 2016 127:504-508, 2017.

Comparison of Videostroboscopy and High-speed Videoendoscopy in Evaluation of Supraglottic Phonation

OBJECTIVES

To compare clinicians' ratings of videolaryngoscopy (VLS) and high-speed videoendoscopy (HSV) and assess confidence of ratings with VLS and HSV in patients with supraglottic phonation.

METHODS

The VLS and HSV video samples were taken from 11 adolescents post airway reconstruction who use supraglottic tissues for voice. The 22 recordings were randomized and presented to 4 clinicians: 2 speech-language pathologists and 2 pediatric otolaryngologists. Additionally, a 5-point Likert scale was used to rate level of confidence of ratings.

RESULTS

Clinicians were more likely to rate regularity on HSV versus VLS videos (P = .003). Presence of mucosal wave was rated similarly on both imaging modalities; however, HSV was more likely to identify location (P = .002). Supraglottic phase symmetry (P = .014) and number of vibratory tissues used for phonation were rated more often with HSV versus VLS. Clinicians were more confident with HSV ratings compared to VLS ratings for determining vibration source, vibration pattern, and ability to make treatment decisions (P < .0001).

CONCLUSIONS

The HSV improves the ability to rate tissue vibratory characteristics when compared with VLS in children with supraglottic phonation. This information may allow better understanding of the underlying mechanisms of voice production in these individuals, leading to improved therapeutic and surgical recommendations.

Foresight in Laryngology and Laryngeal Surgery: A 2020 Vision

Laryngology and laryngeal surgery have been in the vanguard of minimally invasive human procedural interventions for approximately 150 years. The natural passages through the oral cavity, nose, and pharynx have provided an accessible gateway to the larynx that has allowed for rapid translation of a variety of diagnostic and therapeutic technologies. Transoral and transcervical laryngeal surgery have been further facilitated by progressive advancements in local, topical, intravenous, and general anesthesia. With rapid developments in engineering disciplines (ie, tissue, chemical, mechanical) and voice science, there are a variety of current and near-term opportunities to advance our field. This report represents a panel at the 2005 American Broncho-Esophagological Association meeting that sought to use present perspectives, combined with cutting-edge research insights, to provide foresight into key aspects of laryngology that we believe will be developed by the year 2020. We hope that aspiring laryngeal surgeons will find elements of this discussion valuable for devising a strategic roadmap for research initiatives in laryngology and laryngeal surgery.

Quantification of Porcine Vocal Fold Geometry

OBJECTIVE

The aim of this study was to quantify porcine vocal fold medial surface geometry and three-dimensional geometric distortion induced by freezing the larynx, especially in the region of the vocal folds.

STUDY DESIGN

The medial surface geometries of five excised porcine larynges were quantified and reported.

METHODS

Five porcine larynges were imaged in a micro-CT scanner, frozen, and rescanned. Segmentations and three-dimensional reconstructions were used to quantify and characterize geometric features. Comparisons were made with geometry data previously obtained using canine and human vocal folds as well as geometries of selected synthetic vocal fold models.

RESULTS

Freezing induced an overall expansion of approximately 5% in the transverse plane and comparable levels of nonuniform distortion in sagittal and coronal planes. The medial surface of the porcine vocal folds was found to compare reasonably well with other geometries, although the compared geometries exhibited a notable discrepancy with one set of published human female vocal fold geometry.

CONCLUSIONS

Porcine vocal folds are qualitatively geometrically similar to data available for canine and human vocal folds, as well as commonly used models. Freezing of tissue in the larynx causes distortion of around 5%. The data can provide direction in estimating uncertainty due to bulk distortion of tissue caused by freezing, as well as quantitative geometric data that can be directly used in developing vocal fold models.

Voice quality in laryngotracheal stenosis: impact of dilation and level of stenosis

OBJECTIVE

To assess the impact of suspension microlaryngoscopy with balloon dilation on voice-related quality of life (V-RQOL) in laryngotracheal stenosis (LTS).

METHODS

Retrospective chart review of LTS patients dilated at a tertiary-care academic hospital from 2010 to 2013. Data were obtained and then analyzed. LTS was stratified by (1) subglottic or tracheal stenosis and (2) multilevel stenosis (MLS; glottic and subglottic/tracheal). Pre- and postoperative V-RQOL and grade, roughness, breathiness, asthenia, strain (GRBAS) scores were compared. The number and frequency of balloon dilation procedures over the lifetime were secondary outcome variables.

RESULTS

Thirty-eight patients were identified: 26 subglottic/tracheal and 12 multilevel. Of these, 71.4% required multiple dilations, with greatest dilations/patient for multilevel stenosis (4.8). V-RQOL improved in the 27 patients with completed pre- and postoperative scores from a mean of 70.4 to 80 (P=.025). Pre/postoperative V-RQOLs for tracheal/subglottic (mean, 82.8/93.8) were significantly higher (P=.0001/.0001) than multilevel stenosis (48/55.3). Voice quality-of-life improvement was significant for the subglottic/tracheal cohort (P=.036) but not for the MLS group. GRBAS was performed pre- and postoperatively in 10 patients with improvement in all domains except breathiness.

CONCLUSION

Laryngotracheal stenosis is associated with dysphonia. Patients with glottic involvement have significantly worse voice quality of life than those with tracheal/subglottic stenosis. Endoscopic balloon dilation improves V-RQOL in patients with subglottic/tracheal stenosis.

Surgical Management of Posterior Glottic Diastasis in Children

Introduction:

The purpose of this study was to report our clinical experience in the surgical management of patients with posterior glottic diastasis (PGD) secondary to prolonged intubation and/or laryngotracheoplasty (LTP) during childhood.

Methods:

We reviewed the charts of patients with a history of prolonged intubation and/or LTP who had undergone surgical correction for PGD at our institution between 2010 and 2014. We documented demographic data and pertinent information regarding medical and surgical histories. The Pediatric Voice Handicap Index (pVHI) and/or the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) were used to assess patients both before and after undergoing treatment for voice disorders.

Results:

Six patients met our inclusion criteria. With 1 exception, all patients with complete voice data demonstrated improvements in perceptual, patient-reported, and acoustic voice measures. There were no perioperative complications.

Conclusion:

Our case series demonstrates that operative intervention can lead to improved voice in carefully selected patients with PGD secondary to prolonged intubation and/or LTP during childhood. Patients exhibited postoperative improvement in loudness and vocal endurance; however, they also exhibited a degree of compromise in voice quality.

The dysphonic videolaryngoscopy with stroboscopy paradox and challenge of acquired subglottic stenosis after laryngotracheal reconstruction

OBJECTIVE

There's no greater challenge in pediatric laryngology than diagnosis and treatment of chronic dysphonia following laryngotracheal reconstruction of acquired subglottic stenosis. Videolaryngoscopy with stroboscopy provides incomparable diagnostic information to fiberoptic endoscopy. Unfortunately, this pediatric subpopulation which would benefit the most from videolaryngoscopy with stroboscopy infrequently does. We present the unique videolaryngostroboscopic patterns with their diagnostic and treatment implications in this complex population.

METHODS

From a total database of 113 children with histories of subglottic stenosis and/or airway reconstruction between January 1, 2000 and September 30, 2011, successive frames of recorded videolaryngostroboscopies in twenty-three dysphonic children were reviewed. These stroboscopies were compared to age and gender matched controls with dysphonia due to vocal nodules consecutively analyzed from the time period 2009-2011. To validate the similarity of our patient population to others previously reported, we also collected the standardized perceptual, acoustic, and aerodynamic measures of voice analysis and parent/patient reported quality of life.

RESULTS

The voices of patients' pre- and post-airway reconstruction are typically moderately breathy and harsh in voice quality with the majority exhibiting a restricted pitch range and vocal strain. Reduced vocal volume intensity and low habitual speaking pitch were common. Overall, the severity of voice fell within the moderately dysphonic range. Despite universal glottic aperture incompetence, muscle tension dysphonia of the true vocal cords was seen. The glottic muscle tension was confirmed indirectly by noting a consistent "posterior cricoarytenoid bulge." In addition, our group termed a unique pattern of "circumferential supraglottic squeeze" which included both lateral plica ventricularis (false vocal folds) and anteroposterior squeeze opposing the arytenoids to the epiglottic petiole (termed by our group as "arytenoid hooding"). In no patients were the true vocal cords fully visualized. While superficially appearing as hyperfunction, these findings paradoxically represented compensation for laryngeal hypofunction marking the hyperfunction not the problem but a symptom. Actual "mucosal waves" were seen involving the false vocal cords.

CONCLUSIONS

Videolaryngoscopy with stroboscopy results in patterns that are not only unique to patients after airway reconstruction for subglottic stenosis but are also critical for both surgical and non-surgical treatment of chronic dysphonia in these children.

Endoscopic CO2 laser laryngofissure in pediatric laryngotracheal reconstruction

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

Influence of subglottic stenosis on the flow-induced vibration of a computational vocal fold model

The effect of subglottic stenosis on vocal fold vibration is investigated. An idealized stenosis is defined, parameterized, and incorporated into a two-dimensional, fully-coupled finite element model of the vocal folds and laryngeal airway. Flow-induced responses of the vocal fold model to varying severities of stenosis are compared. The model vibration was not appreciably affected by stenosis severities of up to 60% occlusion. Model vibration was altered by stenosis severities of 90% or greater, evidenced by decreased superior model displacement, glottal width amplitude, and flow rate amplitude. Predictions of vibration frequency and maximum flow declination rate were also altered by high stenosis severities. The observed changes became more pronounced with increasing stenosis severity and inlet pressure, and the trends correlated well with flow resistance calculations. Flow visualization was used to characterize subglottal flow patterns in the space between the stenosis and the vocal folds. Underlying mechanisms for the observed changes, possible implications for human voice production, and suggestions for future work are discussed.

Effect of inferior surface angle on the self-oscillation of a computational vocal fold model

Geometry of the human vocal folds strongly influences their oscillatory motion. While the effect of intraglottal geometry on phonation has been widely investigated, the study of the geometry of the inferior surface of the vocal folds has been limited. In this study the way in which the inferior vocal fold surface angle affects vocal fold vibration was explored using a two-dimensional, self-oscillating finite element vocal fold model. The geometry was parameterized to create models with five different inferior surface angles. Four of the five models exhibited self-sustained oscillations. Comparisons of model motion showed increased vertical displacement and decreased glottal width amplitude with decreasing inferior surface angle. In addition, glottal width and air flow rate waveforms changed as the inferior surface angle was varied. Structural, rather than aerodynamic, effects are shown to be the cause of the changes in model response as the inferior surface angle was varied. Supporting data including glottal pressure distribution, average intraglottal pressure, energy transfer, and flow separation point locations are discussed, and suggestions for future research are given.

Posterior Glottic Diastasis: Mechanically Deceptive and Often Overlooked

Dysphonia secondary to posterior glottic aerodynamic incompetence can often be recognizable acoustically, but difficult to document visually. This mechanical impairment in posterior glottic closure is the result of injury caused by airway instrumentation. The difficulty of recognition of this entity is due to posterior supraglottic soft tissue that obscures the complete view during posterior glottic adduction, the lack of a structural organization of the cricoarytenoid region injury that leads to this disorder, and the lack of nomenclature. A retrospective assessment was done on 3 patients who underwent surgical reconstruction to correct posterior phonatory incompetence subsequent to laryngotracheal intubation. All 3 had sustained an injury to the cricoarytenoid joints, and 2 of the 3 had undergone paraglottic space medialization laryngoplasty that failed to solve the posterior glottic insufficiency. New procedures were designed and performed in these patients to correct the posterior glottic incompetence and are described: Laryngofissure and partial posterior cricoid resection, endoscopic pharyngoepiglottic-aryepiglottic fold advancement-rotation flap with interarytenoid interposition, and interarytenoid submucosal implant augmentation. Although the academic literature is replete with reports describing stenosis resulting from impaired cricoarytenoid joint abduction, the term glottic diastasis provides nomenclature for the inability to normally adduct the arytenoid cartilages. The initial experience with surgical reconstruction is preliminary, but encouraging.

Quality of Life and Voice Outcomes after Thyroid Ala Graft Laryngotracheal Reconstruction in Young Children

Objectives. (1) To assess the long-term impact of thyroid ala cartilage laryngotracheal reconstruction (TAC-LTR) on health-related quality of life (QOL) in infants using 4 validated instruments: Health Utility Index version 3 (HUI3), Pediatric Voice-Related QOL (PVRQOL), Impact on Family Questionnaire, and a visual analog scale and (2) to perform acoustic and perceptual voice assessments to evaluate long-term voice quality outcomes.

Study Design. Prospective study.

Setting. Tertiary academic pediatric hospital.

Subjects. Eligible children who received TAC-LTR before the age of 24 months between 1995 and 2007.

Methods. Interviews with parents and children using 4 validated instruments, voice analyses, and endoscopic evaluation were performed.

Results. Twelve patients (7 male, 5 female, median age 10 years) were enrolled over a 6-month period. The mean age at LTR was 5 months (range, 1-20 months), and the mean study follow-up period was 9 years (range, 2-14 years). The average speech HUI3, PVRQOL, and Impact on Family scores were 0.83 (95% confidence interval = 0.74, 0.92), 0.93 (interquartile range [IQR] = 0.81, 1.00), and 0.65 (IQR = 0.54, 0.92), respectively. All acoustic scores were either normal or mildly abnormal for the variables jitter, shimmer, noise-to-harmonic ratio, peak amplitude variation, and fundamental frequency. The Consensus Auditory-Perceptual Evaluation of Voice overall severity score was in the normal to mildly abnormal range for 8 of 9 patients.

Conclusion. This is the first study to explore and quantify long-term QOL and voice quality in children following LTR with thyroid ala graft at a very young age. Most patients had very good functional voice outcome as evidenced by the HUI3 and PVRQOL scores. This was corroborated by acoustic and perceptual voice assessments.

Long-term voice outcome following partial cricotracheal resection in children for severe subglottic stenosis

OBJECTIVE

To correlate the postoperative voice outcome to preoperative glottic involvement, following partial cricotracheal resection (PCTR) in children. The glottic involvement was analysed based on the extent of subglottic stenosis (SGS) in the endoscopic image and functional dynamic assessment using flexible endoscopy.

METHODS

We conducted an interobserver study in which two ENT surgeons, blinded to one another's interpretation, independently rated the extent of SGS based on the endoscopic image along with the dynamic functional airway assessment, of 108 children who underwent PCTR for grade III or IV stenosis. Based on the observation, the glottic involvement was rated into 4 categories: Evaluation of the voice was based on a parent/patient proxy questionnaire sent in 2008 to assess the current functional status of the patient's voice.

RESULTS

Among the 77 patients available for long-term outcome with a minimum 1-year follow-up, 31 patients had isolated SGS free from vocal cords (group A) and 30 had SGS reaching the under surface of vocal cords with partial or no impairment of abduction of vocal cords (group B). Twelve patients belonged to group C with posterior glottic stenosis and/or vocal cord fusion (without cricoarytenoid ankylosis) and 4 patients had transglottic stenosis and or/bilateral cricoarytenoid ankylosis (group D). The long-term voice outcome following PCTR as perceived by the parent or patient was normal in 18% (14 of 77 patients) and the remaining 63 patients demonstrated mild to severe dysphonia. Patients belonging to group A and B exhibited either normal voice or mild dysphonia. Patients in group C demonstrated dysphonia, which was moderate in severity in the majority (83%). All patients in group D with transglottic stenosis and/or CAA showed severe dysphonia.

CONCLUSION

Children with associated glottic involvement are at high risk for poor voice outcome following PCTR. The severity of dysphonia was found to be proportional to the preoperative glottic involvement. Preoperative rating of the extent of glottic involvement based on endoscopic image and dynamic assessment was found to be useful in prognosticating the voice outcome.

Aerodynamic and acoustic assessment in children following airway reconstruction: an assessment of feasibility

OBJECTIVE

The purpose of this study was to examine the feasibility of conducting aerodynamic and acoustic assessment in children following airway reconstruction. Underlying etiologies, co-morbidities and age related factors can present challenges for meaningful instrumental data collection in this population.

METHODS

A chart review of 100 children who were seen for a complete voice evaluation at the Center for Pediatric Voice Disorders at the Cincinnati Children's Hospital Medical Center was conducted. Children who completed full or partial aerodynamic and acoustic protocols were identified. Data regarding the ability to participate in the assessment was tabulated, and vowel samples taken from the acoustic data were subjected to signal type classifications (e.g., Type I, II, III).

RESULTS

Fifty-three children met the inclusion/exclusion criteria of the chart review. Of those children, 58% (n=31/53) were able to complete the full acoustic and aerodynamic protocols without any modification. In regards to the aerodynamic protocol alone, 64% (n=34/53) could complete protocol. In regards to the acoustic protocol alone, 75% (n=40/53) could complete the entire acoustic protocol without any modification. There were 32% (n=17) who provided a Type I acoustic signal which was appropriate for measurement of F(0). There was a significant correlation between age and ability to complete the protocol for both the aerodynamic (p=.007) and acoustic (p=.004) protocols.

CONCLUSIONS

This study demonstrated that a majority of children were capable of completing aerodynamic and acoustic protocols. A significant proportion of children in this study had severe dysphonia, precluding the ability to extract fundamental frequency. Although aerodynamic and acoustic measures are feasible for many patients in this population, the severity of dysphonias observed in these patients causes the use of these measures to be limited in some cases for documenting behavioral and surgical outcomes measures.

Role of Subglottal Shape in Turbulence Reduction

Objectives:

In previous work, we found that airflow at the superior edge of the vocal folds, in the excised canine larynx, can be laminar even when the tracheal airflow is predominantly turbulent. Turbulent flow directly above the folds may lead to an irregular or “rough” voice. Thus, it is important to determine the mechanism of turbulence reduction. From fluid mechanics, it is known that a smoothly converging duct will reduce turbulence. In this study, we tested the hypothesis that the majority of the turbulence reduction is due to the smooth converging shape of the subglottis.

Methods:

In 3 excised canine larynges, hot-wire anemometry was used to measure the turbulence intensity (TI) below the cricoid cartilage and 2 to 3 mm above the superior edge of the vocal folds. Laminar flow was seen when the TI was approximately less than 2%. For our measurements, flow into the subglottis had an average TI of more than 20% (high turbulence) in the shear layer and a TI of more than 15% in the center of the jet. The larynges were tested under steady conditions (folds not phonating) with the vocal processes approximated.

Results:

For the center of the jet, there is moderate turbulence below the cricoid cartilage and laminar flow 2 to 3 mm above the folds. For the shear layer, there is very high turbulence below the cricoid cartilage and low turbulence 2 to 3 mm above the folds.

Conclusions:

The smooth converging shape of the subglottis can produce a significant reduction in turbulence. These findings may have important voice implications for operations that may change the subglottal shape (such as vocal fold medialization or airway reconstruction).

Describing pediatric dysphonia with nonlinear dynamic parameters

OBJECTIVE

Nonlinear dynamic analysis has emerged as a reliable and objective tool for assessing voice disorders. However, it has only been tested on adult populations. In the present study, nonlinear dynamic analysis was applied to normal and dysphonic pediatric populations with the goal of collecting normative data. Jitter analysis was also applied in order to compare nonlinear dynamic and perturbation measures. This study's findings will be useful in creating standards for the use of nonlinear dynamic analysis as a tool to describe dysphonia in the pediatric population.

METHODS

The study included 38 pediatric subjects (23 children with dysphonia and 15 without). Recordings of sustained vowels were obtained from each subject and underwent nonlinear dynamic analysis and percent jitter analysis. The resulting correlation dimension (D2) and percent jitter values were compared across the two groups using t-tests set at a significance level of p=0.05.

RESULTS

It was shown that D2 values covary with the presence of pathology in children. D2 values were significantly higher in dysphonic children than in normal children (p=0.002). Standard deviations indicated a higher level of variation in normal children's D2 values than in dysphonic children's D2 values. Jitter analysis showed markedly higher percent jitter in dysphonic children than in normal children (p=0.025) and large standard deviations for both groups.

CONCLUSION

This study indicates that nonlinear dynamic analysis could be a viable tool for the detection and assessment of dysphonia in children. Further investigations and more normative data are needed to create standards for using nonlinear dynamic parameters for the clinical evaluation of pediatric dysphonia.

Foresight in laryngology and laryngeal surgery: a 2020 vision

Laryngology and laryngeal surgery have been in the vanguard of minimally invasive human procedural interventions for approximately 150 years. The natural passages through the oral cavity, nose, and pharynx have provided an accessible gateway to the larynx that has allowed for rapid translation of a variety of diagnostic and therapeutic technologies. Transoral and transcervical laryngeal surgery have been further facilitated by progressive advancements in local, topical, intravenous, and general anesthesia. With rapid developments in engineering disciplines (ie, tissue, chemical, mechanical) and voice science, there are a variety of current and near-term opportunities to advance our field. This report represents a panel at the 2005 American Broncho-Esophagological Association meeting that sought to use present perspectives, combined with cutting-edge research insights, to provide foresight into key aspects of laryngology that we believe will be developed by the year 2020. We hope that aspiring laryngeal surgeons will find elements of this discussion valuable for devising a strategic roadmap for research initiatives in laryngology and laryngeal surgery.

Vibratory source, vocal quality and fundamental frequency following pediatric laryngotracheal reconstruction

OBJECTIVE

Surgeons who perform pediatric laryngotracheal reconstruction (LTR) have traditionally measured outcomes based on successful airway restoration. Additional information regarding post-surgical vocal function may help guide outcomes toward optimal voice. This investigation documented the relationship between the site of vocal tract vibratory source (glottic versus supraglottic versus mixed) and vocal function in children following LTR.

METHODS

Endoscopic evaluation of voice source was completed in 16 participants who had LTR as children. Three judges rated vocal quality using the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V). Acoustic analysis was completed to obtain fundamental frequency and determine the periodicity of the vibratory signal.

RESULTS

Seven participants were identified to have glottic vibration and nine had supraglottic or mixed-source vibration for voice. All participants were rated as having some degree of voice disorder. Those who used primarily supraglottic/mixed phonation exhibited significantly worse overall severity, roughness, and pitch deviance ratings than did those who used primarily glottic phonation. Significant differences in strain were also noted; however, poor inter-rater reliability rating of strain confounded this result. No significant differences in breathiness or loudness ratings were exhibited. Periodic vibration was observed in 10 of 16 participants (5 of 7 in the glottic group and 5 of 9 in the supraglottic/mixed group). Three of the five participants who had periodic supraglottic phonation had fundamental frequency measures (F(0)) that were below normative ranges, 1 approximated normal, and 1 was above normal range. Two of the five participants who had periodic glottic phonation had lower than expected F(0)s, 1 was within normal range, and 2 were high.

CONCLUSIONS

As observed in earlier studies, voices produced with supraglottic phonation were generally less acceptable than those with glottic phonation. However, phonation with supraglottic structures yielded highly variable voice that may be amenable to change. Some children achieved periodic vibration with alternate structures, suggesting inherent flexibility and adaptability in the tissues used to make sound.

Examination of aerodynamic measures and strain by vibratory source

OBJECTIVES

Patients with laryngotracheal stenosis often require airway reconstruction. Following surgical intervention, voicing may be produced with either a glottic or supraglottic vibratory source. The objective of this study was to compare average airflow, estimated subglottal pressure, and expert perceptual rating of strain between children with glottic and supraglottic vibratory sources post-airway reconstruction.

STUDY DESIGN

This study was a non-randomized prospective study conducted at the Cincinnati Children's Hospital Medical Center (CCHMC), Center for Pediatric Voice Disorders, and included 12 participants with a diagnosis of subglottic stenosis, post-laryngotracheal reconstruction.

RESULTS

Expert perceptual ratings of strain were significantly higher for participants with supraglottic versus glottic voicing (P = 0.0001). Although the mean airflow measure was higher for participants with glottic phonation and mean pressure measure was higher for those with supraglottic voicing, these comparisons failed to reach significance.

CONCLUSIONS

Patients who exhibit supraglottic phonation patterns demonstrate greater strain during speech, as well as potential alterations to aerodynamic patterns.

SIGNIFICANCE

The significant differences in perceived strain by vibratory source are noteworthy, as perceptual quality is always a patient's motivation to seek treatment.

Pediatric Laryngotracheal Stenosis and Airway Reconstruction: A Review of Voice Outcomes, Assessment, and Treatment Issues

Laryngotracheal stenosis is defined as a congenital or acquired narrowing of the airway. Congenital causes may include subglottic membranous or cartilaginous narrowing. Acquired causes may include trauma due to prolonged endotracheal or tracheal intubation or laryngotracheal injury. Although advances have been made over the past 30 years in reconstructive surgeries to improve airway patency in these patients, long-term laryngeal function for voice production is not well defined in this population. This review examines causes, symptoms and signs, and methods for diagnosing laryngotracheal stenosis. Surgical management procedures are briefly summarized. The current literature on voice outcomes is summarized. The predominant voice characteristics in the population are presented, although results are challenged by the heterogeneity of voice presentation and paucity of data from instrumental measures. Considerations for subjective and instrumental assessment, measures of quality of life, instrumental methods, and treatment options specific to the needs of this population are discussed. Research strategies to identify long-term outcomes of surgical and behavioral treatments in this population are posed.

Potential role of Sox9 in patterning tracheal cartilage ring formation in an embryonic mouse model

OBJECTIVE

To identify genes expressed early in the formation of the mouse trachea that control patterning of tracheal cartilaginous rings.

DESIGN

The mouse larynx and trachea begin as an outpouching from the ventral foregut endoderm at embryonic day (E) 9. Digoxigenin-labeled RNA probes to putative tracheal patterning genes were generated by in vitro transcription. Embryos ranging in age from E9 to E16 were then subjected to whole-mount in situ hybridization using these labeled RNA probes. The RNA probes were then localized using antidigoxigenin antibodies tagged with a reporter molecule. In this manner, the 3-dimensional spatial and temporal expression of putative tracheal patterning genes was examined. Subjects F/VBN mice.

RESULTS

In the developing mouse trachea, the expression of Sox9 messenger RNA preceded cartilage ring formation. Sox9 was expressed as 2 distinct longitudinal stripes along the posterolateral aspect of the trachea as early as E9, when the developing trachea is first identified. Collagen 2A1, a cartilage-specific protein, was subsequently expressed in the same longitudinal pattern as Sox9, consistent with the early commitment of Sox9-expressing cells to the cartilage program. As cartilage rings formed, Sox9 and collagen 2A1 was expressed over the lateral and anterior aspects of the trachea.

CONCLUSIONS

We have developed a system to study the early expression of genes that may pattern the formation of the trachea. We have identified a gene (Sox9) with a known role in chondrocyte differentiation that is expressed in a highly specific temporal and spatial pattern in the developing upper respiratory tract.

Voice quality of prepubescent children with quiescent recurrent respiratory papillomatosis

OBJECTIVE

The purpose of this study was to assess the long-term impact of recurrent respiratory papillomatosis (RRP) and its treatment on voice quality in prepubescent children.

STUDY DESIGN

Case-control study.

METHODS

Prepubescent children with RRP in remission for at least 12 [according to MM section] months were asked to participate. Remission was documented by absence of papillomas on fiberoptic flexible laryngoscopy. An age- and sex-matched control was selected for each patient enrolled. Voice was evaluated using the voice-related quality of life (V-RQOL) questionnaire, perceptual evaluations of voice quality by speech-language pathologists using the GRBAS (grade of hoarseness, roughness, breathiness, asthenia, strain) scale, and acoustic analysis (fundamental frequency, maximal phonation time, and relative average perturbation) using the Visi-Pitch II 3300.

RESULTS

Medical records of 84 patients were reviewed and 15 met study criteria. Five agreed to participate but one was excluded due to the presence of papillomas. The four study patients and four matched controls were between 9- and 11-years old. On the V-RQOL questionnaire, each control rated V-RQOL as normal (10/50) and the average patient group score was within the normal range (11.5/50). On perceptual evaluations, the patient's voices were more hoarse, breathy, and rough compared to controls'. Acoustic analysis showed that patients' voices had a lower average fundamental frequency (F(0)) (200 Hz compared to 243 Hz for controls) and a higher relative average perturbation (RAP) (1.10 compared to 0.77), although only one patient's voice actually had elevated RAP (2.89), which had a large impact on raising the average score for the patient group. The average maximal phonation times were similar for the two groups (7.8s for patients and 7.4s for controls) but lower than average normal scores reported in the literature.

CONCLUSIONS

Although children with RRP do not perceive their voice quality to have a negative impact on V-RQOL, speech-language pathologist evaluations and acoustic measurements show objective differences between the voices of children with quiescent RRP and those of normal, healthy controls.

Phonomicrosurgery in singers and performing artists: treatment outcomes, management theories, and future directions

Phonomicrosurgery in performing artists has historically been approached with great trepidation, and vocal outcome data are sparse. The vocal liability of surgically disturbing the superficial lamina propria (SLP) and epithelium must be balanced with the inherent detrimental vocal effect of the lesion(s). A prospective investigation was performed on 185 performing artists who underwent phonomicrosurgical resection of 365 lesions: 201 nodules, 71 polyps, 66 varices and ectasias, 13 cysts, 8 keratotic lesions, 2 granulomas, 2 Reinke's edema, and 2 papillomas. Nearly all patients with SLP lesions reported improvement in their postsurgical vocal function. This subjective result was supported by objective acoustic and aerodynamic measures. All postsurgical objective vocal function measures fell within normal limits, including a few that displayed presurgical abnormalities. However, given the relative insensitivity of standard objective measures to assess higher-level vocal performance-related factors, it is even more noteworthy that 8 of 24 objective measures displayed statistically significant postsurgical improvements in vocal function. Such changes in objective measures mostly reflect overall enhancement in the efficiency of voice production. Phonomicrosurgical resection of vocal fold lesions in performing artists is enjoying an expanding role because of a variety of improvements in diagnostic assessment, surgical instrumentation and techniques, and specialized rehabilitation. Most of these lesions are the result of phonotrauma and arise within the SLP. Successful management depends on prudent patient selection and counseling, ultraprecise technique, and vigorqus vocal rehabilitation. Furthermore, an understanding of the vocal function and dysfunction of this high-performance population provides all otolaryngologists who manage laryngeal problems with valuable information that they can extrapolate for use in their practices.

Bilateral vocal fold posterior glottic/subglottic stenotic web resected with contact tip Nd-YAG laser

The standard treatment for respiratory failure remains endotracheal intubation, with periods of 22 or more days being commonplace. Posterior glottic stenotic web formation, from scarring in the posterior interarytenoid area, may occur after endotracheal intubation, thermal, corrosive, or direct surgical injury. A commonly used classification system for posterior glottic stenosis divides the occurrence into four types. Type I involves an interarytenoid scar band between the vocal folds that is anterior and separate from the posterior interarytenoid mucosa. Type II stenosis involves scarring of the mucosa or musculature of the posterior interarytenoid area. Types III and IV involve unilateral and bilateral cricoarytenoid joint fixation, respectively. Strobovideolaryngoscopy (SVL), rigid and flexible fiberoptic bronchoscopy, electromyography (EMG), radiologic imaging of the neck, larynx, and trachea as well as pulmonary function tests, including flow volume loops, provide important objective measurements of upper airway obstruction. A representative case of a professional voice user who suffered a Type II posterior glottic stenosis is presented. The treatment utilized a specific contact-tip neodymium-yttrium aluminum garnet (Nd-YAG) laser delivery system to achieve precise cutting, vaporization, and coagulation simultaneously, returning tactile touch technique to the airway/voice surgeon. Completely successful restoration of voice and airway have been maintained for 2 1/2 years postoperatively.

Longitudinal survey of voice quality after pediatric laryngotracheoplasty

This study assesses the effect of pediatric laryngotracheoplasty on voice quality. A group of ten children who underwent laryngotracheoplasty with thyrotomy and anterior cartilage graft were examined two or more times after decannulation and their voices were compared to those of sex- and age-matched controls. Each examination included a laryngoscopy, evaluation by a speech/language pathologist and measurement of maximum phonation times and fundamental frequencies using the Signalyse program. The strength of the voices and the maximum phonation times gradually improved. The fundamental frequency became lower with age, as in the controls. The data suggest that laryngotracheoplasty does not hamper the development of voice with age in children and that the voice improves without any further surgery, although hoarseness remains.

Voice disorders in children

Pediatric patients with voice or speech problems usually should receive a team assessment in which communication between the pediatrician or primary care physician, the otolaryngologist, and speech pathologist occurs. Although speech or voice problems may prompt an otolaryngologic evaluation, the voice or speech problem simply may be the manifestation or symptom of a larger or more complex disease process. Whether that is the case of hypernasal speech, eventually leading to the diagnosis of velocardiofacial syndrome, or bilateral vocal fold paralysis, eventually leading to the diagnosis of hydrocephalus, it is apparent that patients with speech or voice disorders may eventually require multidisciplinary evaluation. The outlook for children with speech and voice difficulties is better than ever. Recent equipment advances, such as flexible laryngoscopy, video stroboscopy, and nasometry, for detection, evaluation, and management of speech problems have created a better environment than ever existed for care of these problems. Much research is being performed in the area of pediatric voice and speech problems. The National Institute of Deafness and Communicative Disorders and the National Institute of Dental Research have funded and currently fund many projects in these areas. Many pediatric hospitals now have voice or speech disorder clinics in which multiple disciplines are brought together to evaluate children with these problems. Children benefit best when speech and voice problems are managed in an interdisciplinary setting when necessary and by professionals who have experience and training in these specialized pediatric problems. Given the local, professional, and national resources that are expended toward recognition and treatment of speech disorders in children, it is truly a tragedy when those resources cannot be brought to assist children with voice and speech problems. Although voice and speech problems usually are recognized by parents or concerned family members, this task may rest on the pediatrician or other primary caregiver.

Treatment of Voice Disorders in Medically Complex Children

A recent prevalence study revealed that laryngeal pathologies, including subglottic stenosis, laryngomalacia, vocal cord paralysis, and papillomatosis, are common in children. Children with these and other organically based alterations in laryngeal structure and/or function, frequently referred to the speech-language pathologist, often present with complex medical profiles. There is, however, a paucity of information to guide the clinician in diagnosing and treating voice problems associated with such laryngeal pathologies in children. This article presents individual case studies that detail information regarding management decisions and specific treatment options that have been implemented with medically complex children with voice disorders. The case studies demonstrate that there is an opportunity to improve vocal function in medically complex children.

Long-term airway considerations after treatment of severe pediatric laryngotracheal stenosis in five children

After initial treatment of severe laryngotracheal stenosis (LTS), we evaluated subsequent airway function. Five children between 2 and 11 years were treated previously for severe LTS by T-tube stenting. One case underwent subsequent laryngotracheal reconstruction. All patients demonstrated dyspnea, the severity of which increased with age and duration of time after completion of stenosis treatment. In the most severe cases, magnetic resonance imaging and endoscopy revealed secondary subglottic stenosis. Ventilatory function tests disclosed obstruction of both extrathoracic and pulmonary origin. These findings raise questions regarding the treatment of the initial stenosing tissue and of the secondary stenoses.

Formal reintubation for incipient neonatal subglottic stenosis

In a small prospective series of 10 children who presented with incipient subglottic stenosis following neonatal intubation a protocol of formal reintubation for two weeks, with sedation, enabled six of the children to avoid tracheostomy or other forms of surgery and in the remaining four it is unlikely that the trial of reintubation made the degree of laryngeal and subglottic damage worse.