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Vilarello BJ, Maurrasse S, Grunstein E, Jang M. Vocal Cord Paralysis in Pediatric Chiari Malformation: A Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg 2024. [PMID: 38953205 DOI: 10.1002/ohn.884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 05/26/2024] [Accepted: 06/09/2024] [Indexed: 07/03/2024]
Abstract
OBJECTIVE Arnold-Chiari Malformation is one possible cause of congenital vocal cord paralysis (VCP). The natural history of VCP in children with Chiari malformation has previously been limited to small case studies. This systematic review seeks to better characterize the prognostic factors that may predict symptom severity and resolution of congenital VCP in children with Arnold-Chiari malformation. We hypothesized that the onset of stridor or VCP at a younger age would be associated with a poorer prognosis and earlier intervention with posterior fossa decompression would be associated with better outcomes. DATA SOURCES PubMed, Web of Science, Cochrane Library, and bibliographic review. REVIEW METHODS A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Database search yielded 866 articles. Study abstracts were reviewed by 2 independent examiners. One hundred and seventy-six studies underwent full-text review. The following were extracted: age at onset of stridor or VCP, Chiari malformation type, laryngoscopy findings, type and timing of neurosurgical intervention, and tracheostomy history. Statistical analyses utilized χ2 tests. RESULTS Younger age at symptom onset showed statistically significant associations with decreased likelihood for symptom resolution and tracheostomy decannulation. The shorter time interval from symptom onset to neurosurgical intervention was not significantly associated with better outcomes. CONCLUSION This meta-analysis suggests poorer prognosis in those with earlier-onset symptoms, reinforcing prior case series findings. Additional prospective studies are needed to elucidate the natural history and utility of early intervention in children with vocal cord paralysis secondary to Chiari malformation.
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Affiliation(s)
- Brandon J Vilarello
- Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Sarah Maurrasse
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Eli Grunstein
- Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
- Department of Otolaryngology-Head and Neck Surgery, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
| | - Minyoung Jang
- Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
- Department of Otolaryngology-Head and Neck Surgery, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
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Patel B, Muston H, Pitman RT. Brain imaging abnormalities in children with dysphagia with aspiration: A retrospective study. J Pediatr Gastroenterol Nutr 2024; 78:52-56. [PMID: 38291689 DOI: 10.1002/jpn3.12055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 09/26/2023] [Accepted: 09/27/2023] [Indexed: 02/01/2024]
Abstract
OBJECTIVE Head imaging is often performed in children with persistent dysphagia with aspiration to evaluate for Chiari malformations that may be associated with dysphagia. Unfortunately, the frequency of Chiari malformations or other head imaging abnormalities in children who aspirate is unknown. The goal of this study is to determine the frequency of head imaging abnormalities in children with evidence of aspiration or penetration on video fluoroscopic swallow study (VFSS). SETTING Tertiary Children's Hospital. METHODS We performed retrospective analysis of children with a diagnosis of aspiration evaluated at our center from January 2010 through April 2021. In this study, we included children with VFSS confirmed aspiration or penetration, brain magnetic resonance imaging (MRI) performed at our center, and without known genetic, congenital craniofacial, or neurologic abnormalities. RESULTS Of the 977 patients evaluated in our system during that time with a diagnosis of aspiration, 185 children met the inclusion criteria. Eight children were diagnosed with Chiari malformations (4.3%) and 94 head MRIs were abnormal (51.4%). There was no difference in VFSS findings (frequency of aspiration, penetration, penetration-aspiration score, or recommended thickness of liquid) in children with a Chiari malformation versus other abnormalities or normal brain imaging. The majority of other non-Chiari brain imaging abnormalities were nonspecific. There was no difference in VFSS findings in children with abnormal MRI findings versus normal MRI. CONCLUSIONS Brain imaging abnormalities are common in children who aspirate. Intervenable lesions are rare. Further studies are required to determine patients that will most likely benefit from brain imaging.
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Affiliation(s)
- Bhumi Patel
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Heather Muston
- Department of Pediatrics, Division of Pediatric Pulmonology Allergy and Immunology, Indiana University, Indianapolis, Indiana, USA
| | - Ryan T Pitman
- Department of Pediatrics, Division of Pediatric Gastroenterology, Indiana University, Indianapolis, Indiana, USA
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How to manage children who aspirate and fail conventional treatments. OTOLARYNGOLOGY CASE REPORTS 2021. [DOI: 10.1016/j.xocr.2021.100314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Whited T, Stevenson S. An 8-Month Old With Choking Episodes. J Pediatr Health Care 2021; 35:624-629. [PMID: 34736560 DOI: 10.1016/j.pedhc.2021.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 05/27/2021] [Accepted: 06/07/2021] [Indexed: 11/29/2022]
Abstract
This case report presents a female infant whose chief complaint of choking episodes resulted in a diagnosis of Chiari malformation type I and subsequent neurosurgical decompression. Although feeding difficulties and irritability are common complaints in pediatric primary care, dysphagia requires a more significant workup to identify a cause. This case report highlights red flags in the history and diagnostic studies and provides details for managing an unusual presentation of Chiari malformation type I.
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Ene CI, Wang AC, Collins KL, Bonow RH, McGrath LB, Durfy SJ, Barber JK, Ellenbogen RG. Expansile duraplasty and obex exploration compared with bone-only decompression for Chiari malformation type I in children: retrospective review of outcomes and complications. J Neurosurg Pediatr 2020; 27:1-8. [PMID: 33126216 PMCID: PMC8085180 DOI: 10.3171/2020.6.peds20376] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 06/29/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE While a select population of pediatric patients with Chiari malformation type I (CM-I) remain asymptomatic, some patients present with tussive headaches, neurological deficits, progressive scoliosis, and other debilitating symptoms that necessitate surgical intervention. Surgery entails a variety of strategies to restore normal CSF flow, including increasing the posterior fossa volume via bone decompression only, or bone decompression with duraplasty, with or without obex exploration. The indications for duraplasty and obex exploration following bone decompression remain controversial. The objective of this study was to describe an institutional series of pediatric patients undergoing surgery for CM-I, performed by a single neurosurgeon. For patients presenting with a syrinx, the authors compared outcomes following bone-only decompression with duraplasty only and with duraplasty including obex exploration. Clinical outcomes evaluated included resolution of syrinx, scoliosis, presenting symptoms, and surgical complications. METHODS A retrospective review was conducted of the medical records of 276 consecutive pediatric patients with CM-I operated on at a single institution between 2001 and 2015 by the senior author. Imaging findings of tonsillar descent, associated syrinx (syringomyelia or syringobulbia), basilar invagination, and clinical assessment of CM-I-attributable symptoms and scoliosis were recorded. In patients presenting with a syrinx, clinical outcomes, including syrinx resolution, symptom resolution, and impact on scoliosis progression, were compared for three surgical groups: bone-only/posterior fossa decompression (PFD), PFD with duraplasty (PFDwD), and PFD with duraplasty and obex exploration (PFDwDO). RESULTS PFD was performed in 25% of patients (69/276), PFDwD in 18% of patients (50/276), and PFDwDO in 57% of patients (157/276). The mean follow-up was 35 ± 35 months. Nearly half of the patients (132/276, 48%) had a syrinx. In patients presenting with a syrinx, PFDwDO was associated with a significantly higher likelihood of syrinx resolution relative to PFD only (HR 2.65, p = 0.028) and a significant difference in time to symptom resolution (HR 2.68, p = 0.033). Scoliosis outcomes did not differ among treatment groups (p = 0.275). Complications were not significantly higher when any duraplasty (PFDwD or PFDwDO) was performed following bone decompression (p > 0.99). CONCLUSIONS In this series of pediatric patients with CM-I, patients presenting with a syrinx who underwent expansile duraplasty with obex exploration had a significantly greater likelihood of syrinx and symptom resolution, without increased risk of CSF-related complications, compared to those who underwent bone-only decompression.
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Affiliation(s)
- Chibawanye I. Ene
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Anthony C. Wang
- Department of Neurosurgery, University of California, Los Angeles, California
| | | | - Robert H. Bonow
- Department of Neurological Surgery, University of Washington, Seattle, Washington;,Harborview Injury Prevention Research Center, University of Washington, Seattle, Washington
| | - Lynn B. McGrath
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Sharon J. Durfy
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Jason K. Barber
- Department of Neurological Surgery, University of Washington, Seattle, Washington
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Doerga PN, Rijken BFM, Bredero-Boelhouwer H, Joosten KFM, Neuteboom RF, Tasker RC, Dremmen MHG, Lequin MH, van Veelen MLC, Mathijssen IMJ. Neurological deficits are present in syndromic craniosynostosis patients with and without tonsillar herniation. Eur J Paediatr Neurol 2020; 28:120-125. [PMID: 32782184 DOI: 10.1016/j.ejpn.2020.06.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 05/18/2020] [Accepted: 06/23/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Children with syndromic craniosynostosis (sCS) have a higher incidence of cerebellar tonsillar herniation (TH) than the general population. In the general population, TH ≥ 5 mm below the foramen magnum is associated with typical neurological deficits but, in sCS, we do not know whether this degree of TH is required before such deficits occur. OBJECTIVE This prospective cohort study aimed to determine the association between findings on neurological assessment and cerebellar tonsillar position. METHODS Magnetic resonance imaging (MRI) was used to determine TH ≥ 5 mm and the presence of syringomyelia. In regard to the outcome of neurological deficits, these were categorized according to: A, cerebellar function; B, cranial nerve abnormalities; and C, sensory or motor dysfunction. RESULTS Twenty of 63 patients with sCS (32% [95% confidence interval 21-45%]) had TH ≥ 5 mm and/or syringomyelia. There was no significant difference in proportion between individual forms of sCS: 16/34 Crouzon, 2/11 Muenke, 2/12 Apert, and 0/7 Saethre-Chotzen patients. Neurological deficits were prevalent (73% [95% confidence interval 60-83%]), and as frequent in patients with TH ≥ 5 mm and/or syringomyelia as those without. Surgery occurred in 3 patients overall, and only in Crouzon patients. CONCLUSION Determining the effect of TH ≥ 5 mm on neurologic functioning in sCS patients is used to better determine when surgical intervention is warranted. However, we have found that neurological deficits are prevalent in sCS patients, irrespective of cerebellar tonsillar position, suggesting that such findings are developmental and, in part, syndrome-specific central nervous system features.
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Affiliation(s)
- P N Doerga
- Department of Plastic and Reconstructive Surgery and Hand Surgery, Sophia Children's Hospital, Dutch Craniofacial Center, Erasmus MC, University Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.
| | - B F M Rijken
- Department of Plastic and Reconstructive Surgery and Hand Surgery, Sophia Children's Hospital, Dutch Craniofacial Center, Erasmus MC, University Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - H Bredero-Boelhouwer
- Department of Plastic and Reconstructive Surgery and Hand Surgery, Sophia Children's Hospital, Dutch Craniofacial Center, Erasmus MC, University Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - K F M Joosten
- Pediatric Intensive Care Unit, Sophia Children's Hospital, Erasmus MC, University Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - R F Neuteboom
- Department of Pediatric Neurology, Sophia Children's Hospital, Erasmus MC, University Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - R C Tasker
- Department of Anaesthesia (Pediatrics) and Division of Critical Care Medicine, Harvard Medical School and Boston Children's Hospital, 300 Longwood Avenue, Boston, Massachusetts, 02115, USA
| | - M H G Dremmen
- Department of Neurosurgery, Sophia Children's Hospital, Erasmus MC, University Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - M H Lequin
- Department of Radiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
| | - M L C van Veelen
- Department of Neurosurgery, Sophia Children's Hospital, Erasmus MC, University Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - I M J Mathijssen
- Department of Plastic and Reconstructive Surgery and Hand Surgery, Sophia Children's Hospital, Dutch Craniofacial Center, Erasmus MC, University Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
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Torres-Silva CA. Chronic Pulmonary Aspiration in Children: Diagnosis and Management. Curr Probl Pediatr Adolesc Health Care 2018; 48:74-81. [PMID: 29571544 DOI: 10.1016/j.cppeds.2018.01.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Chronic pulmonary aspiration (CPA) is a common cause of morbidity in children with complex aerodigestive disorders. CPA can be caused by swallowing dysfunction, anatomic, or dynamic abnormalities of the airways, and/or other circumstances that overcome the child's natural capacity to protect the airway. Diagnostic evaluation for suspected aspiration aims to characterize the swallowing function, identify the etiology of aspiration, including anatomic and/or dynamic abnormalities causing aspiration, and evaluate for the development of aspiration sequelae (e.g., bronchiectasis). CPA management approach should be guided by the recognized risk factors and co-morbidities, and directed to decrease the events of aspiration, improve clearance of aspirated material, and limit the development of aspiration sequelae (e.g., chronic inflammation and recurrent infections). This article presents a practical approach for the diagnosis and management of chronic pulmonary aspiration (CPA) in children.
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Affiliation(s)
- Cherie A Torres-Silva
- Division of Pulmonary Medicine at Cincinnati Childrens Hospital Medical Center, Cincinnati, OH.
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