Swallowing dysfunction among patients with laryngeal cleft: More than just aspiration?

Congenital laryngo-tracheo-esophageal clefts: updates from a quaternary care pediatric airway unit

PURPOSE

To review the operative techniques, outcomes, and complications following surgery in pediatric patients with laryngo-tracheo-esophageal clefts (LTEC). We describe a new combined approach to treat long LTECs.

METHODS

Twenty-five patients underwent surgical repair for LTEC from March 2012 to July 2022 at our hospital. Every patient underwent a diagnostic endoscopy under general anesthesia and spontaneous ventilation to assess the LTEC and synchronous aero-digestive comorbidities/malformations. All patients underwent at least one surveillance endoscopy after the repair at our institution.

RESULTS

The patients had multiple other malformations, specifically gastro-intestinal, synchronous airway, and cardiac. The cleft distribution according to the modified Benjamin and Inglis classification was type I (n = 5, 20%), type II (n = 6, 24%), type IIIa (n = 8, 32%), type IIIb (n = 4, 16%), and type IVa (n = 2, 8%). The median follow-up was 44.6 months. Five patients (20%) had undergone previous cleft corrective surgery(s). Seven patients (28%) had partial to complete breakdown of the repair, needing additional intervention(s), and two required a combined-open plus endoscopic repair. Preoperatively, most patients (n = 18, 72%) needed a feeding assistance. At latest follow-up, feeding assistance was weaned off in 13 out of 18 patients, which was a 72% improvement. Ten patients (40%) needed ventilation assistance before the surgery. Post-operatively, ventilatory assistance was weaned off in 6 patients, meaning a 60% improvement.

CONCLUSION

LTEC are rare malformations, and their management needs precise diagnosis, appropriate surgical planning, and execution, and dedicated post-operative care. Primary and revision repair of long clefts with tracheal extension may require a combined approach.

Outcomes of Injection Laryngoplasty for Deep Interarytenoid Groove

Introduction  Deep interarytenoid groove (DIG) may cause swallowing dysfunction in children; however, the management of DIG has not been established. Objective  We evaluated the subjective and objective outcomes of interarytenoid augmentation with injection in children with DIG. Methods  Consecutive children under 18 years of age who underwent injection laryngoplasty for DIG were reviewed. Data pertaining to demographics, past medical history, past surgical history, and results of pre and postoperative video fluoroscopic swallow study (VFSS) were obtained. The primary outcome measure was the presence of thin liquid aspiration or penetration on postoperative VFSS. The secondary outcome measure was caregiver-reported improvement of symptoms. Results  Twenty-seven patients had VFSS before and after interarytenoid augmentation with injection (IA). Twenty (70%) had thin liquid penetration and 12 (44%) had thin liquid aspiration before the IA. Thin liquid aspiration resolved in 9 children (45%) and persisted in 11 (55%). Of the 12 children who had thin liquid aspiration prior to IA, 6 (50%) had resolution of thin liquid aspiration after IA. Conclusions  Injection laryngoplasty is a safe tool to improve swallowing function in children with DIG. Further studies are needed to assess the long-term outcomes of IA and identify predictors of successful IA in children with DIG.

Consensus on level descriptors for a functional children's eating and drinking activity scale

AIM

To agree wording of level descriptors for a measure of functional outcome of children's eating and drinking.

METHOD

An online, modified Delphi method was used to gather feedback on current level descriptor wording and generate rewording suggestions. Thirty speech and language therapists, working in a variety of settings and geographical locations, were invited to be part of the Delphi expert panel. Content analysis was used to evaluate participants' comments and develop consensus level descriptors. Consensus for acceptable wording was set at 80% agreement. Face validity was assessed using 5-point Likert scales.

RESULTS

Nineteen expert speech and language therapists (median experience 18 years) completed round one; 15 out of 19 completed round two. Level descriptor rating reached 80% agreement in two rounds. Additionally, 93% of participants agreed the scale would accurately capture change in their setting, with 87% likely to use the scale in practice.

INTERPRETATION

This study has produced agreed wording for a functional measure of eating and drinking activity suitable for use with paediatrics feeding disorders, regardless of disease aetiology, presentation, age, or setting. Potential for widespread use is supported. Further evaluation of the tool's reliability and validity is required.

Spectrum of swallowing abnormalities in children with Type I laryngeal cleft

OBJECTIVES

To describe the spectrum of swallowing abnormalities in children with Type I laryngeal cleft (LC-1) and evaluate the effect of LC-1 repair on swallowing abnormalities.

METHODS

A retrospective review was performed of all consecutive children who were diagnosed with LC-1. Swallowing function was evaluated pre- and post-operatively using video fluoroscopic swallow study (VFSS). VFSS reports were used to define swallowing abnormalities and to determine penetration aspiration scale (PAS) and functional oral intake scale (FOIS). Prevalence of swallowing abnormalities, PAS, and FOIS scores were compared before and after repair of LC-1.

RESULTS

Fifty-seven children with LC-1 had VFSS. The majority of children (86%) had a combination of oral phase, swallow triggering, pharyngeal phase, or esophageal phase impairment. The pharyngeal phase impairment was the most prevalent abnormality (p < 0.001). Esophageal phase impairment was the least prevalent VFSS abnormality (p < 0.001). Prevalence of impaired pharyngeal phase, laryngeal penetration on thin and thick liquids, and silent aspiration was less after repair of LC-1. Fourteen patients (41%) had developmentally appropriate diet with no restrictions after surgery. Nine patients (27%) required positioning and therapy strategies while having developmentally appropriate diet. PAS score after surgery was less than PAS score prior to surgery (p < 0.001). FOIS score after surgery was not different than FOIS score before surgery.

CONCLUSIONS

Multiple phases of swallowing function were impaired in the majority of children with LC-1. Prevalence of swallowing abnormalities varied in the subgroups of gender, gestational age, race, and presence of comorbidity. Swallowing function improved after repair of LC-1.

Endoscopic Repair of Laryngeal Clefts: 8 Years' Experience

To emphasize the need for high clinical suspicion in the diagnosis of Laryngeal cleft in paediatric population, to catalogue the pattern of presentation, time to treatment and the evolution of surgical techniques for Laryngeal cleft repair at our center. A retrospective review of laryngeal cleft cases which presented over a period of 8 years (May 2012-May 2020), from a tertiary care center, was done. Data includes-patient demographics, preliminary investigations, diagnostic methods, type of cleft, surgical steps and post-operative follow up. Extensive literature search was done and we could not find similar studies from South East Asia and the Indian subcontinents. Of the 10 patients 7 were managed surgically and 3 conservatively. There was an equal distribution of type 1 (n = 5) and 2 (n = 5) clefts. 80% cases were males and 9 out of 10 patients had associated congenital anomalies. 80% cases had symptom resolution (75% were managed surgically and 25% managed medically). Surgical intervention should be based on the extent of anatomical defect and the functional impairment caused by cleft such as respiratory problems, persistence of feeding issues despite maximal medical management and feeding therapy. Early surgical management of type I and II clefts have satisfactory outcomes.

Surgical Treatment of Type III Laryngotracheoesophageal Clefts: Techniques and Outcomes

OBJECTIVES/HYPOTHESIS

Determine surgical and swallowing outcomes after surgery for type III laryngotracheoesophageal cleft (LTEC).

STUDY DESIGN

Case series with chart review.

METHODS

Chart review was performed on patients with type III LTEC between 2000 and 2019. Demographics, surgical outcomes, and swallowing outcomes were collected and analyzed.

RESULTS

Thirty-three patients met inclusion criteria (28 open and 5 endoscopic repairs). Mean age was 3.4 years for the open group and 0.9 years for the endoscopic group. Seventeen (51.5%) patients had a syndromic diagnosis, most commonly Opitz syndrome and Trisomy 21. Mean follow-up was 33.6 months. Thirteen (39.4%) patients had a previous repair attempt prior to repair at our institution. Twenty-four (70.6%) patients had a tracheostomy prior to or at the time of surgical repair and 13 (38.2%) remain tracheostomy-dependent. Nine patients (27.3%) required a revision cleft repair and four (12.1%) required two revisions. Thirty-one patients had an intact repair at last follow-up (93.9). Two patients died outside the hospital over a year after surgery. Preoperatively 13 of 17 patients with swallowing evaluations aspirated. After repair, 11 of 20 patients were deemed safe for all consistencies and seven were safe for thickened. Endoscopic approaches were performed during the last 2 years of the study and had significantly lower operative time (354.4 minutes vs. 171.5 minutes).

CONCLUSIONS

Endoscopic and open approaches are effective for treatment of type III LTEC with 27.3% requiring revision and 93.9% of repairs intact at last follow-up. Overall swallowing outcomes were good in patients who underwent postoperative instrumental swallow evaluation.

LEVEL OF EVIDENCE

IV Laryngoscope, 2021.

Current management of type III and IV laryngotracheoesophageal clefts: the case for a revised cleft classification

PURPOSE OF REVIEW

This review summarizes the paediatric laryngotracheoesophageal cleft (LTEC) literature, with an emphasis on recent trends, evaluation and management, surgical techniques, postoperative care of Type III and IV LTECs, and to propose a revised cleft classification system that more accurately reflects our current understanding of these anomalies.

RECENT FINDINGS

There are a number of techniques described to address Type III and IV LTEC, from endoscopic to open approaches with thoracotomy. The surgical approach should be tailored to the length of the cleft and its proximity to important anatomical structures. On the basis of review of the literature, we propose a modified Benjamin-Inglis classification (MBI) with subcategories to address this issue. Postoperative complications are common, namely, tracheoesophageal fistulae and tracheomalacia, which may necessitate subsequent procedures or prolonged tracheostomy dependence.

SUMMARY

The medical and surgical management of Type III and IV LTEC is challenging with a high rate of morbidity and mortality. The rarity and difficulties in management of these malformations have made large cohort studies difficult, thus generalizable recommendations have been elusive. Experience and patient selection are critical for successful endoscopic repair. Anterior cervical approach, often with complete laryngofissure, appears to be the most common and preferred method for open repairs, though some use a lateral approach. The proposed MBI classification appears to be a useful adjunct to aid in surgical decision-making for deeper LTEC.

Injection Laryngoplasty for the Treatment of Type 1 Laryngeal Clefts: A Single Institution Experience

OBJECTIVE

Standards for treatment of laryngeal clefts remain poorly defined. There are no large case series that report the efficacy of injection laryngoplasty (IL) in the treatment of pediatric Type 1 laryngeal clefts (LC-1). The objective of this study is to measure the effect of IL in young children with LC-1.

METHODS

A retrospective case series of 130 patients was completed over 3 years at a at a single institution included patients aged 1 month to 8 years, diagnosed with aspiration and penetration issues during swallowing based on a Videofluoroscopic Swallow Study (VFSS). Patients underwent surgical evaluation and intervention using carboxymethylcellulose gel injection. Collected data points included age in months at time of first injection, gender, race, pre- and post-operation VFSS scores, number of injections, co-morbidities and post-operative complications. VFSS scores were evaluated pre- and post-operatively to assess efficacy of intervention. A secondary outcome was efficacy in patients with aspiration compared to those with penetration alone.

RESULTS

This study included 77 male and 53 female patients. Sixty-two patients (48%) demonstrated a significant post-operative improvement in their swallowing function (P < .05). There were no statistical differences in age, number of injections, or the volume of the first injection. Patients that showed a post-operative improvement in swallowing function were on average 5 months older and had more severe aspiration and penetration compared to those who did not demonstrate a post-operative benefit and underwent less injections. The volume of injection did not appear to play a role in the success rate.

CONCLUSION

Injecting the inter-arytenoid area in patients with LC-1 appears to confer some benefit to close to half of our patient population. Successful procedures seemed to occur in patients with more severe aspiration and penetration and older age.

Presentation and management of type 1 laryngeal clefts: A systematic review and meta-analysis

OBJECTIVE

To evaluate outcomes of injection laryngoplasty (IL) and endoscopic surgical repair for the treatment of type 1 laryngeal clefts (LC1) and to determine the most common presentations of LC1.

METHODS

Primary studies were searched for in PubMed, Scopus, OVID, and Cochrane Library using search terms laryngeal cleft and laryngotracheoesophageal cleft for articles published from database inception through August 2019. The search identified all articles pertaining to the symptomatology and management of LC1. Meta-analysis was performed on presenting symptoms and improvement of clinical symptoms and swallow function.

RESULTS

Twenty-four studies, comprising 713 patients with a mean age of 33.7 months (range 0-168 months), were included. The most common presenting symptoms were aspiration (80%, CI [55%-96%]), dysphagia (61%, CI [47%-74%]), and choking (57%, CI [37%-76%]). Gastroesophageal reflux disease (GERD) was the most common comorbidity (68%, CI [51%-83%]) and premature birth comprised 27% [21%-32%] of the patients. Overall, 38% of patients received IL as a primary therapy. Prior to injection, 91% [87%-94%] of patients aspirated on swallow evaluations, and 62% [55%-68%] aspirated post-injection. At an average follow-up time of 6.8 months, 90% [70%-100%] of parents reported symptom improvement. An additional 54% of patients underwent endoscopic surgical repair as primary treatment. The rate of aspiration decreased from 73% [43%-94%] to 28% [13%-46%] after repair. At a mean follow-up of 14.2 months, 80% [67%-91%] reported symptom improvement.

CONCLUSION

A high level of clinical suspicion is necessary to detect LC1 since its most common presenting symptoms overlap with other diseases commonly found in this patient population. Both IL and formal surgical repair were effective in managing LC1.

Injection augmentation and endoscopic repair of type 1 laryngeal clefts: development of a management algorithm

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.

Oral aspiration, type 1 laryngeal cleft, and respiratory tract infections in canadian inuit children

Canadian Inuit infants suffer the highest rate of lower respiratory tract infections (LRTI's) in the world. The causes of this are incompletely understood. The primary objective of this study was to determine whether there exists an association between respiratory morbidity and oral aspiration in Inuit children. A retrospective chart review was conducted including children from Nunavut who underwent Video Fluoroscopic Swallowing Study between the years of 2001 to 2015. The primary outcome was hospitalization for LRTI. We hypothesized that infants found to have aspiration would experience a higher rate of admissions for LRTI than those with normal swallowing studies. One-hundred and twenty-seven patients were identified, of whom 94 were included. Fifty-six percent of patients had an abnormal swallowing study. Compared with patients with normal swallowing, the incidence rate of LRTI was higher in patients with aspiration (incidence rate ratio [IRR] = 1.51; 95% confidence interval [CI] = 1.23-1.87) and in patients with penetration (IRR = 1.40; 95% CI = 1.11-1.76). Fourteen percent of patients had confirmed laryngeal cleft; patients with confirmed presence of this also had a higher incidence rate of LRTI (IRR = 1.66; 95% CI = 1.32-2.07). The incidence of abnormal swallowing study showed an 11-fold variation across the five regions in Nunavut, with the highest prevalence in west Qikiqtani Region (Baffin Island). We conclude that swallowing dysfunction is not only prevalent amongst Canadian Inuit but clinically significant. This is the first study to demonstrate an association between swallowing dysfunction and respiratory morbidity in this population. Geographic distribution patterns and high rates of laryngeal cleft may point to a potential genetic etiology for what remains at this point, idiopathic swallowing dysfunction.

Associations between age, respiratory comorbidities, and dysphagia in infants with down syndrome

OBJECTIVES

Children with Down syndrome (DS) have a high risk of dysphagia and the pediatric pulmonologist may be involved in diagnosis and management. The objective of this study is to evaluate the associations between age, dysphagia, and medical comorbidities in young children with DS. We hypothesized that swallow study findings are more likely to change in younger infants and that medical comorbidities may be associated with dysphagia.

STUDY DESIGN

Results of videofluoroscopic swallow studies (VFSS) and fiberoptic endoscopic evaluation of swallowing (FEES) from 2010 to 2016 were collected retrospectively in children with DS with initial swallow study at less than 12 months of age. Results were analyzed for findings and change based on age at initial study, reason for referral, and medical comorbidities.

RESULTS

One hundred eleven infants with 247 VFSS and 14 FEES were included. Deep laryngeal penetration and/or aspiration were found in 31.9% of infants less than 6 months and 51.3% of infants 6 to 12 months. Children with initial swallow study performed at greater than or equal to 6 months of age were more likely (80.0%) to have unchanged findings on follow-up study compared to children imaged at less than 6 months (35.3%). Laryngomalacia, pulmonary hypertension, pneumonia, and congenital cardiac disease were associated with dysphagia.

CONCLUSION

We confirmed that dysphagia is common in infants with DS and comorbidities and provided preliminary evidence that swallow study findings may be more likely to change in children tested under 6 months of age. Providers should consider that results for instrumental swallow studies may change, particularly if the test was completed on a young infant.

Natural history of silent aspiration on modified barium swallow studies in the pediatric population

OBJECTIVES

To investigate the natural history of silent aspiration in the pediatric population.

METHODS

Retrospective chart review of patients (age < 3 years) who underwent modified barium swallow studies (MBSS), between January 1, 2007, to December 31, 2017, were studied to compare comorbidities and determine course of resolution in those with silent aspiration.

RESULTS

A total of 148 charts were reviewed. Patients that underwent surgical intervention for laryngeal anomalies causing silent aspiration and those with overt aspiration or oral aversion were excluded. Of the 56 patients in the study, 25 had silent aspiration and 31 demonstrated no silent aspiration on MBSS. There was a higher rate of overall comorbidities amongst silent aspirators (96.0% vs. 48.4%, p=0.003) in comparison to patients with no silent aspiration on MBSS. Silent aspirators had higher rates of cerebral palsy (16.0% vs. 0%, p=0.034), and seizures (36.0% vs. 3.2%, p=0.003). Of the 20 patients with silent aspiration with an MBSS completed beyond the initial one, 13 (65.0%) experienced resolution, 5 (20.0%) did not experience resolution by age 5, and 2 (10.0%) had unknown resolution due to being lost to follow up or not yet reaching age 5. No statistically significant associations were found between comorbidities, gender, presence of a gastrostomy tube and resolution.

CONCLUSIONS

Silent aspiration in children is associated with neurological comorbidities, particularly cerebral palsy and seizures. More than half of the patients with silent aspiration spontaneously resolve over time. Expectant management, close surveillance, and clinical assessments can be considered in these patients on an individual basis.

Repair of type IV laryngotracheoesophageal cleft (LTEC) on ECMO

PURPOSE

A type IV laryngotracheoesophageal cleft (LTEC) is a very rare congenital malformation. Type IV LTEC that extends to the carina have poor prognosis and are difficult to manage. We present our experience with surgical repair in such a case using extracorporeal membranous oxygenation (ECMO).

METHODS

A male infant, who was diagnosed with Goldenhar syndrome, showed severe dyspnea and dysphagia. Laryngoscopy indicated the presence of LTEC. The patient was transferred to our institute for radical operation 26 days after birth. Prior to surgery, a balloon catheter was inserted in the cardiac region of stomach through the lower esophagus to block air leakage, to maintain positive pressure ventilation. We also performed observations with a rigid bronchoscope to assess extent of the cleft, and diagnosed the patient with type IV LTEC. After bronchoscopy, we could intubate the tracheal tube just above the carina. Under ECMO, repair of the cleft was performed by an anterior approach via median sternotomy.

RESULTS

The patient was intubated via nasotracheal tube and paralysis was maintained for 2 weeks, using a muscle relaxant for the first 3 days. Two weeks after surgery, rigid bronchoscopy showed that the repair had been completed, and the tracheal tube was successfully extubated without tracheotomy.

CONCLUSIONS

Although insertion of a balloon catheter is a very simple method, it can separate the respiratory and digestive tracts. This method allowed for positive pressure ventilation and prevented displacement of the endotracheal tube until ECMO was established. As a result, we safely performed the operation and the post-operative course was excellent.

Deep interarytenoid notch in young children managed with systematic thickener wean and injection laryngoplasty

OBJECTIVES

Deep interarytenoid notch (DIN) is a congenital variation of the larynx often associated with dysphagia and aspiration (DA) in young children. Feeding therapy with thickeners and surgical management with injection larygoplasty (IL) are used with various efficacies. Thickeners address the functional domain and IL addresses the anatomical domain of treatment. Our objective was to evaluate DIN patients managed with both interventions.

METHODS

We conducted a retrospective pilot descriptive study of DIN patients with DA aged 1-3 years receiving thickeners and IL. Patients received a systematic weekly reduction of thickeners, referred to as the Thickener Weaning Protocol (TWP), based on clinical signs and symptoms of DA. The outcomes were assessed by the rate of thickener level reduction and DA-related sign/symptom frequency achieved at 6 months post-treatment.

RESULTS

Thirteen patients with DIN associated DA were analyzed. The TWP was initiated within 2 months in 77% of patients, and within 4 months in 100% of patients. Thickener scores improved from an average of 5.76 (3/4 honey) to 2.15 (thin) (p = 0.001). DA-related signs/symptoms frequency improved from an average of 3.3 to 0.84 (p = 0.05).

CONCLUSIONS

These findings suggest that treatment of DIN associated DA with a combination of thickeners and IL results in significant clinical improvements in young children.

A Mild Laryngeal Cleft Causes Severe Symptoms

Diagnosis and treatment of laryngeal clefts (LCs) particularly type I pose a challenge. Although rare, type I LCs are becoming increasingly identified in recent years, and this is perhaps due to both an increased awareness and better diagnostic modalities. We report a young infant presenting with feeding difficulty and respiratory distress related to LC. The pertinent literature is also reviewed.

Feeding Interventions Are Associated With Improved Outcomes in Children With Laryngeal Penetration

OBJECTIVES

To determine if children with laryngeal penetration on videofluoroscopic swallow study (VFSS) who received feeding interventions (thickened liquids, change in liquid flow rate, and/or method of liquid delivery) had improved symptoms and decreased hospitalizations compared with those without intervention.

METHODS

We performed a retrospective cohort study of children under 2 years with laryngeal penetration on VFSS at our institution in 2015 to determine initial and follow-up VFSS findings, symptom improvement at follow-up, and hospitalization risk before and after VFSS. Proportions were compared with Fisher exact test and hospitalizations with paired t tests.

RESULTS

We evaluated 137 subjects with age 8.93 ± 0.59 months who had laryngeal penetration without aspiration on VFSS. Fifty-five percent had change in management, with 40% receiving thickening and 15% a change in flow rate. There was significant improvement in symptoms for children that had feeding intervention and this improvement was the greatest with thickening (OR 41.8, 95% CI 12.34-141.69, P < 0.001). On repeat VFSS, 26% had evidence of aspiration that was not captured on initial VFSS. Subjects had decreased total and pulmonary hospitalizations with feeding intervention and decreased pulmonary nights with thickening (P < 0.05).

CONCLUSIONS

Laryngeal penetration appears to be clinically significant in children with oropharyngeal dysphagia and interventions to decrease its occurrence are associated with improved outcomes including decreased symptoms of concern and hospitalization nights. Thickening or other feeding intervention should be considered for all symptomatic children with laryngeal penetration on swallow study.

Pediatric dysphagia: Is interarytenoid mucosal height significant?

OBJECTIVES

The clinical significance of the interarytenoid mucosal height (IAMH) in pediatric dysphagia, ranging from normal anatomy to a laryngeal cleft, is unknown. This study seeks to evaluate a cohort of patients who underwent evaluation of their IAMH during microdirect laryngoscopy (MDL) for associations between IAMH and dysphagia as diagnosed on preoperative videofluoroscopic swallow study (VFSS).

METHODS

A retrospective case series of 1,351 patients who underwent MDL between 2011 and 2016 were reviewed for intraoperative evaluation of IAMH using our interarytenoid assessment protocol. After exclusions, 182 patients were divided into three groups: 1) thickened diet: VFSS with recommendation for thickened liquids (n = 82 of 182; 45.1%), 2) normal diet: VFSS with allowance of thin liquids (n = 19 of 182; 10.4%), and 3) control: no VFSS performed (n = 81 of 182; 44.5%).

RESULTS

There was no difference in IAMH between groups (P = 0.35). Power analysis was able to achieve > 80% power to detect an effect size of ≥ 0.5 (1-5 mucosal height scale). The majority of patients in each group had an IAMH above the false vocal folds (thickened diet: 57.3%, normal diet: 57.9%, control: 64.2%). There were similar percentages of patients in each group with an IAMH at or below the true vocal folds (thickened diet: 4.9%, normal diet: 5.3%, control: 6.1%).

CONCLUSION

There was no significant association between IAMH and preoperative thickened liquid recommendation in this cohort. This data fails to support the hypothesis that the IAMH is an independent etiological factor for pediatric pharyngeal dysphagia. Further studies comparing IAMH with outcomes after feeding therapy and surgery may better clarify this relationship between anatomy and physiology.

LEVEL OF EVIDENCE

4. Laryngoscope, 129:2588-2593, 2019.

Psychometrics of the Functional Oral Intake Scale for Infants

This study aimed to investigate the reliability and validity of the Functional Oral Intake Scale (FOIS) for infants. Infants (age, <1 year) who underwent a videofluoroscopic swallowing study (VFSS) were included in this retrospective study. Their nutrition records at the time of the VFSS were separately evaluated by two raters using the five-point FOIS for infants. Categorical swallowing and aspiration impairment scale data were also obtained from the VFSS. The inter-rater reliability of the FOIS for infants was high (95.5% absolute agreement) among the 201 evaluated infants, and this scale was significantly correlated with aspiration severity in the VFSS. We also investigated whether infants with partial oral feeding (POF) at the FOIS evaluation had achieved full oral feeding within 1 year of the evaluation and used this information to estimate whether the caloric contribution, as well as consistency of oral feeding, affected the feeding outcomes. This analysis included 33 infants who were receiving both oral and tube feeding (i.e., POF). Among them, 26 infants achieved full oral feeding (FOF) without tube feeding after 1 year. Their initial contribution from oral feeding was higher than that in infants who still maintained POF after 1 year (28.46 ± 22.79 vs. 6.00 ± 5.45%, p < 0.001). The five-point FOIS for infants, which reflected the expansion of their oral diet with growth, had adequate reliability and validity. The caloric contribution as well as consistency of oral feeding could be used to distinguish FOIS levels 2 and 3, which correspond to the POF status in infants.

Neonatal Stridor: Diagnosis and Management

Stridor, a common presenting sign of respiratory distress in a newborn, has many systemic causes. It may arise from the larynx or the tracheobronchial airway. This article presents the most common pathologic conditions in this anatomic region, with highlights on management.

Postextubation Dysphagia in Children: The Role of Speech-Language Pathologists

OBJECTIVES

Postextubation dysphagia is common and associated with worse outcomes in the PICU. Although there has been an increased participation of speech-language pathologists in its treatment, there is limited evidence to support speech-language pathologists as core PICU team member. We aimed to assess the impact of speech-language pathologists interventions on the treatment of postextubation dysphagia.

DESIGN

A quasi-experimental prospective study. In the historical group (controls), patients received a standard care management for dysphagia whereas the intervention group was routinely treated by speech-language pathologists.

SETTING

PICU of a tertiary hospital.

PATIENTS

Children who were endotracheally intubated for a period greater than 24 hours with greater oral intake limitation as defined by a Functional Oral Intake Scale less than or equal to 3.

INTERVENTION

Routine speech-language pathologist assessment.

MEASUREMENTS AND MAIN RESULTS

A total of 74 patients were enrolled to receive intervention (January 2015 to December 2016) and 41 patients to the historical group (January 2014 to December 2014). There were no differences in the demographic and clinical characteristics. The historical group had both longer time to initiate oral intake (7 vs 4 d; p = 0.0002; hazard ratio, 2.33) and to reach full oral intake compared with intervention group (9 vs 13 d; p < 0.001; hazard ratio, 2.51). A total of 32 controls (78%) and 74 intervention patients (100%) were on total oral intake at discharge (p ≤ 0.001). Three of nine control patients were feeding tube dependent at hospital discharge. Also, controls had a longer length of hospital stay (25 vs 20 d) and a higher rate of reintubation when compared with those patients of intervention group (10% vs 2%).

CONCLUSIONS

Incorporating speech-language pathologists in the routine management of postextubation dysphagia can result in faster functional improvement and favorable patient outcomes. Yet, further and larger studies in pediatric dysphagia are required to support the related interventions and strategies to guide clinical practice.

Development and validation of a quality of life instrument for patients with laryngeal cleft

OBJECTIVE

To develop and validate a novel pediatric health-related quality of life (HR-QoL) instrument for patients with laryngeal cleft and their families.

METHODS

We surveyed primary caregivers of patients that underwent endoscopic repair of Type I or II laryngeal cleft. The proposed HR-QoL instrument consists of 40 items representing four domains, assessing the patient's physical symptoms, the patient's and family's social functioning, and the family's emotions regarding the patient's illness pre- and post-operatively. Confirmatory factor analysis was employed to assess construct validity, dimensionality, and optimal simple structure.

RESULTS

Of 78 eligible participants reached by phone, 40 (51%) of them completed the questionnaire. Confirmatory factor analysis suggested that all four measured constructs were well supported by the measured items in comparison to a unidimensional model. All factor loadings and factor correlations were significant and factor correlations ranged between 0.723 and 0.879. Indices of test-retest reliability and internal consistency reliability were well above recommended standards. There was a significant correlation between current instrument and PedsQL™ score. The overall QoL score significantly improved from 112.3 (±28.1) before surgery to 158.0 (±28.5) after surgery (mean difference 45.7; 95% CI: 37.3, 54.1; p < 0.001).

CONCLUSION

Our proposed pediatric HR-QoL instrument is a valid tool for measuring quality of life in patients with laryngeal cleft and their families. This instrument can provide insight into the effects of medical and surgical therapy and guide pre- and post-operative management of laryngeal cleft.

An Aerodigestive Approach to Laryngeal Clefts and Dysphagia Using Injection Laryngoplasty in Young Children

PURPOSE OF REVIEW

Our objective is to summarize the presentation, diagnosis, and management of mild laryngeal clefts in children. We focus on deep interarytenoid notches (DIN), a subclassification of type 1 laryngeal clefts (LC1), and review the literature and our multidisciplinary experience utilizing injection laryngoplasty (IL).

RECENT FINDINGS

DIN is a mild form of LC1 and is considered a normal anatomical variant. Recent cohort studies demonstrate IL to be a safe, low-risk, and efficacious treatment of LC1, but few studies focus on DIN. We present results from two aerodigestive clinic (ADC) pilot studies at our institution, in patients 1-3 years old, with DIN-related dysphagia and aspiration (DA). Feeding, respiratory-related symptom scores, and aspiration/penetration assessed on modified barium swallow (MBS) significantly improved following combined IL and feeding therapy using a thickener weaning protocol (TWP). Subgroup analysis reveals combined IL and TWP to be particularly effective in patients with severe baseline DA. Multidisciplinary aerodigestive evaluation and management with IL and feeding therapy focused on weaning levels of thickener is emerging as a novel and effective approach for treatment of DIN-related DA in young children. Further comparative, prospective trials investigating effects of IL and feeding therapy are required to validate results.

International Pediatric Otolaryngology Group: Consensus guidelines on the diagnosis and management of type I laryngeal clefts

INTRODUCTION

The diagnosis and management of type I laryngeal clefts can be controversial and varies across centers and surgeons. Using existing peer-reviewed literature to develop an expert-based consensus will help guide physicians in the treatment of these patients as well as develop research hypotheses to further study this condition.

OBJECTIVE

To provide recommendations for the diagnosis and management of type I laryngeal clefts.

METHODS

Determination of current expert- and literature-based recommendations, via a survey of the International Pediatric Otolaryngology Group, using a modified Delphi method.

SETTING

Multinational, multi-institutional, tertiary pediatric hospitals.

RESULTS

Consensus recommendations include diagnostic workup, medical management, pre-operative, intra-operative and post-operative considerations for type I laryngeal clefts.

CONCLUSIONS

This guide on the diagnosis and management of patients with type I laryngeal clefts is aimed at improving patient care and promoting future hypothesis generation and research to validate the recommendations made here.