The changing face of the paediatric microlaryngobronchoscopy (MLB): A two year prospective study

The changing face of paediatric airway endoscopic surgery: An 8-year single surgeon review

INTRODUCTION

As a recently established division, we sought to reflect on the development of our paediatric airway surgery service, and prospectively examine the diagnoses that underwent microlaryngobronchoscopy (MLB) to help quantify the evolving population demographics of paediatric airway disorders.

MATERIAL AND METHODS

This was a prospective longitudinal study conducted of all paediatric MLBs performed by a single surgeon in a tertiary paediatric ENT centre between 2012 and 2019.

RESULTS

A total of 1040 MLBs were performed in 498 patients at the paediatric ENT centre of the Royal London Hospital. Median age at first procedure was 19 months. Median follow-up was 48 months. Primary diagnoses were laryngomalacia (21%), subglottic stenosis (SGS - 18%), laryngeal cleft (13%), and normal anatomy (28.3%). Repeat procedures were needed in 39.1% patients, who underwent a median of 2 repeat procedures. SGS (57.7%) constituted majority of the repeat category, followed by laryngeal cleft (12.36%), laryngomalacia (10.15%), unilateral/bilateral vocal cord palsy(4.24%) and laryngeal papilloma(4.24%). Laryngeal papilloma constituted largest number of procedures per patient (Median = 4, IQR = 5.75), followed by subglottic web and SGS. Mean length of stay(LOS) was 0.67 ± 0.96 days(d), with laryngeal cleft cases recording longest mean LOS. There was a steady increase in proportion of day-surgeries across study period [6.9% (2012) vs 59%(2019)].

CONCLUSION

SGS constitutes the major bulk of paediatric airway surgery, reflective of increasing number of premature births and prolonged intubation among neonates. Day-case MLB is a safe and feasible option in selected patients. This long-term data provides useful information to accurately prognosticate patients regarding potential number of repeat procedures for each diagnosis.

Inter-rater reliability in diagnosis and treatment of type one laryngeal cleft: A blinded observational study

INTRODUCTION

Type one laryngeal cleft (T1LC) has been implicated as a major contributor to aspiration in non-syndromic pediatric dysphagia. Despite an increasing incidence, there remains controversy in diagnosis and treatment algorithms.

OBJECTIVES

The primary objective of this study was to evaluate the inter-rater reliability (IRR) for the diagnosis and treatment of T1LC.

METHODS

A retrospective analysis was conducted to identify children evaluated for a T1LC from 2016 to 2017 at a single tertiary care center. The microlaryngoscopy video recordings depicting palpation of the interarytenoid region with a right-angle probe were reviewed. These recordings were shown to blinded pediatric otolaryngologists and each surgeon's determination of the presence or absence of a T1LC as well as recommended treatment (observation, injection laryngoplasty, or endoscopic cleft repair) was recorded and compared against the other blinded surgeons. Fleiss's kappa was calculated to evaluate IRR in both diagnosis and treatment.

RESULTS

Eight pediatric otolaryngologists were included in the study with a mean post-training experience of 15 years (range 1-35 years). The inter-rater percent agreement in diagnosis of our patient population was 28.6% (range 3.7-71%) with a kappa value of 0.31 (p < 0.0001). In regard to management, the inter-rater percent agreement in treatment was 11.4% (range 0-35%) with a kappa value of 0.14 (p = 0.01).

CONCLUSION

This study highlights the challenges and variation that exists among surgeons in diagnosing and managing potential T1LC. Further standardizing the endoscopic examination and treatment algorithm may reduce diagnostic and treatment discordance.

Use of the pediatric intensive care unit for post-procedural monitoring in young children following microlaryngobronchoscopy: Impact on resource utilization and hospital cost

OBJECTIVE

To assess the frequency of post-procedural complications, medical interventions, and hospital costs associated with microlaryngobronchoscopy (MLB) in children prophylactically admitted for pediatric intensive care unit (PICU) monitoring for age ≤ 2 years.

METHODS

We performed a single-center, retrospective, descriptive study within a 44-bed PICU in a stand-alone, tertiary, pediatric referral center. Inclusion criteria were age ≤2 years and pre-procedural selection of prophylactic PICU monitoring after MLB between January 2010 and December 2015. Children were excluded for existing tracheostomy, if undergoing concurrent non-otolaryngeal procedures, or if intubated at the time of PICU admission. Primary outcomes were the development of major and minor procedural complications and medical rescue interventions. Secondary outcomes were hospital cost and length of stay (LOS).

RESULTS

One hundred and eight subjects met inclusion criteria with a median age of 5.3 (IQR: 2.6-10.9) months. A majority (86%) underwent therapeutic instrumentation in addition to diagnostic MLB. There were no observed major complications or rescue interventions. Minor complications were noted within 5 h of monitoring and included isolated stridor (24%), desaturation <90% (10%), and nausea/emesis (8%). Minor interventions included supplemental oxygen via regular nasal cannula (39%), single-dose inhaled racemic epinephrine (19%), single-dose systemic corticosteroids (19%), or high flow nasal cannula (HFNC) therapy (4%). Save for two cases of HFNC, interventions were completed or discontinued within 5 h. Median PICU LOS was 1.1 days and median cost was $9650 (IQR: $8235- $14,861) per encounter. Estimated cost of same day observation in our post anesthesia care unit (PACU) following MLB without PICU admission is $1921 per encounter.

CONCLUSIONS

In children ≤ 2 years of age prophylactically admitted for PICU observation, we did not observe severe complications or major interventions after MLB. Minor interventions and complications were noted early during post-procedural monitoring. PICU monitoring was substantially more expensive than same-day PACU observation. Young age as the sole criteria for prophylactic PICU monitoring after diagnostic or therapeutic MLB may be unjustified when comparable, cost-conscious care can be achieved in a PACU setting. Prior to pre-procedural selection of PICU monitoring, we recommend a broad contextual risk assessment including a review of comorbidities, operative plan, and intended anesthetic exposure.