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

Current opinion in otolaryngology and head and neck surgery: the role of the otolaryngologist in the management of pediatric dysphagia

PURPOSE OF REVIEW

Dysphagia affects at least 1% of the pediatric population. This prevalence further increases in patients who are born prematurely or who have underlying neuromuscular or cardiopulmonary disorders. A multidisciplinary team approach, including an Otolaryngologist, can help promote an expedited diagnosis and therapeutic regimen, ensuring that the patient receives adequate nutrition needed for growth and development.

RECENT FINDINGS

The development and growth of multidisciplinary aerodigestive clinics have improved outcomes in pediatric patients with dysphagia. If a structural concern is noted on examination, there remain a multitude of medical and surgical options to help improve patient outcomes and swallow. These treatment options are usually multimodality and specific interventions may be employed to target a specific and notable abnormality.

SUMMARY

Pediatric dysphagia is a complex concern. For the otolaryngologist, etiologies with surgical targets may include ankyloglossia, tonsillar hypertrophy, laryngomalacia, laryngo-esophageal cleft, vocal fold movement impairment, and cricopharyngeal achalasia. The development and formalization of a multidisciplinary approach has streamlined and broadened treatment options for these patients. An otolaryngologist is integral as part of the treatment team of these patients.

Nutritional and feeding challenges in aerodigestive patients

PURPOSE OF REVIEW

Aerodigestive disorders encompass conditions that affect both the airway and gastrointestinal tract. These include conditions such as acquired and congenital defects of the airway and esophagus as well as neuromuscular disorders. Patients often suffer from dysphagia, aspiration, and respiratory disorders. This article will provide a review of current practices in the management of feeding disorders, oropharyngeal dysphagia, and nutritional support in the aerodigestive population.

RECENT FINDINGS

Oral aversion, aspiration, and feeding-tube dependence are all commonly encountered problems in the aerodigestive population. Intensive inpatient and outpatient programs along with use of appetite stimulants and psychotropic medications may help to improve feeding-related disorders. Aspiration affects many patients and requires close monitoring of clinical symptoms along with routine assessment with video fluoroscopy. Developments in blenderized feeds and formula supplementation have also provided new options for patients with feeding intolerance.

SUMMARY

Patients with aerodigestive disorders require complex medical care, and multidisciplinary teams are the most effective in addressing their medical needs. Advances in feeding, occupational, and pharmacologic therapy have allowed healthcare providers to better address the needs of these patients.

Injection laryngoplasty for laryngeal cleft type I in an 8-week-old infant

A laryngeal cleft is a rare anatomical deformity which is increasingly treated with injection laryngoplasty. Since diagnosis of laryngeal cleft type I is often made between 2 and 5 years of age, this treatment is rarely performed on very young children. In this case, we describe how injection laryngoplasty is performed safely on an 8-week-old child, and we illustrate its added value for the diagnostic process and for temporary symptom relief.

Optimal timing and technique for endoscopic management of dysphagia in pediatric aerodigestive patients

INTRODUCTION

The best strategy to manage an interarytenoid defect [Type 1 laryngeal cleft (LC-1) or deep interarytenoid groove (DIG)] in pediatric aerodigestive patients with dysphagia remains uncertain. This study compared benefit of interarytenoid augmentation (IAA) to suture repair or clinical observation alone in pediatric patients.

METHODS

A 3-year retrospective, single-center analysis of children with dysphagia undergoing endoscopic airway evaluation was performed. Physician preference guided treatment plan: suture repair with CO2 laser, IAA (carboxy methylcellulose or calcium hydroxyapatite), or observation. Primary outcome was improved post-operative diet. Significance was assumed at p < 0.05.

RESULTS

449 patients underwent diagnostic endoscopy. Mean age (±SD) at procedure was 21 ± 13 months, with nearly one fourth (28 %) of children ≤ 12 months. Eighty (18 %) had either an LC-1 (n = 55) or DIG (n = 25). Of these, 35 (42 %) underwent suture repair, 22 (28 %) IAA, and 23 (30 %) observation only. Aspiration improved overall in the interventional groups compared to observational controls (58 % vs. 9 %, p < 0.05), with no change in benefit observed by age of intervention. IAA was as effective as suture repair (59 % vs 55 %, p = 0.46). In patients with only a DIG, IAA intervention alone significantly improved swallow function (66.6 % vs. 0 %, p < 0.05).

CONCLUSION

In pediatric aerodigestive patients with dysphagia, 18 % of children have an addressable lesion. IAA or suture repair similarly improves dietary advancement. IAA improves swallow function in patients with DIG. These findings support a novel protocol to intervene in dysphagia patients with LC-1 or DIG via IAA at the initial operative evaluation.

Endoscopic Repair of Type 1 Laryngeal Clefts and Deep Interarytenoid Notches: Cold Steel Versus Laser

OBJECTIVES/HYPOTHESIS

Endoscopic repair is the preferred surgical treatment for type 1 laryngeal clefts (T1LCs) and deep interarytenoid notches (DINs). No studies exist showing differences in repair rates using laser and cold steel. Our objective is to assess overall success and revision rate for endoscopic cleft repair and determine whether there is any difference in surgical outcomes between cold steel and laser techniques.

STUDY DESIGN

Retrospective chart review, cohort study.

METHODS

Retrospective review at a quaternary care pediatric hospital. Included all patients who underwent endoscopic repair for T1LCs and DINs between January 2010 and December 2019. Demographics, comorbidities, surgical data, outcomes, and revision status were collected and analyzed. We excluded patients who did not have a follow-up at our institution.

RESULTS

A total of 194 patients were identified, 14 were excluded for lack of follow-up data so 180 were analyzed. Of these, 127 had cold steel repair and 53 had laser repair. There is no significant difference in demographics or comorbidities. In the cold steel group, 4 of 127 (3.1%) had breakdown and in the laser group, 10 of 53 (18.9%) had breakdown. Patients who failed after a cold steel repair tended to break down later (median 12.7 months) when compared to laser repairs (median 2.1 months). Nine of the 10 patients with breakdown after laser repair were noted on initial postoperative evaluation.

CONCLUSIONS

Endoscopic cleft repair is a well-described and effective method for repair of T1LCs and DINs. Both cold steel and laser have high success rates; however, higher failure rates were noted in the laser repair group. Failure after laser repair may occur earlier than failure after cold steel repair. But this did not reach significance.

LEVEL OF EVIDENCE

III Laryngoscope, 2021.

Thickened liquids: do they still have a place in the paediatric dysphagia toolkit?

PURPOSE OF REVIEW

Use of thickened fluids has long been a cornerstone of dysphagia management. However, clinicians and researchers are increasingly questioning their effectiveness and highlighting potential harms. This review aims to present the current state of the evidence for use of thickened fluids in children.

RECENT FINDINGS

The relationship between aspiration and respiratory infection is complex. The role of thickened fluids in improving respiratory health is limited and contradictory. A high level of variability exists in all aspects of thickened fluid use. Little is known about patient and family perspectives on meaningful endpoints for intervention.

SUMMARY

Clinicians should be open and transparent in their decision making with patients and families, acknowledging the limited evidence and the need for individualised care. Further research is needed to establish the efficacy of thickened fluid use in children with regard to improvements in respiratory health, fluid intake and child and family wellbeing.

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.

Parental management of feeding problems in young children-a population-based study

OBJECTIVES

To investigate the practices that parents use to manage feeding problems in healthy children and in children with gastrointestinal diseases. Secondly, for each of these two groups we examined the association of select child and parent variables with parental feeding practices.

METHODS

This is a cross-sectional case-control study. The sample consisted of 901 children (765 healthy children of typical development and 136 children with gastrointestinal diseases), aged one to seven years. The feeding problem management practices were investigated through 23 closed-ended questions. The anthropometric and demographic data of children and the demographic data of parents were collected by administering structured set of questions to parents.

RESULTS

The prevalence of parent-reported feeding problems was 30.6% for healthy children and 45.7% for children with gastrointestinal diseases. The most common practices adopted by parents of healthy children were highlighting the benefits of food (80.5%), correlating food with pleasure (71.6%) and praising (59.1%), whereas almost half of the parents were found not to accept that their children may not be hungry and insisted on trying to feed them. Statistically significant differences were noted in many parental practices between the two groups. Parents of children with gastrointestinal diseases were generally more involved in the feeding process. Verbal praising (69.1%), correlation with pleasure (79.4%), promotion of benefits (77.2%) as well as assistance during feeding (63.2%) were the most common parental practices in the gastrointestinal group. Age, birth order, being the only child and weight status were child variables that differentiated parental behavior. Parental characteristics that affected feeding practises were age, education and work status.

CONCLUSIONS

A high prevalence of feeding problems was reported by parents of both healthy children and children with gastrointestinal diseases. Beside the presence of a disease, specific child and parent variables are significantly related to parental behavior when managing feeding problems.

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.

Side effects and complications of injection laryngoplasty for treatment of congenital type 1 laryngeal clefts

INTRODUCTION

Injection laryngoplasty (IL) is a brief, minimally invasive procedure involving injection of agents to augment the interarytenoid space. It was initially described as a diagnostic and temporizing measure for management of type one laryngeal clefts (LC1) and associated swallowing dysfunction (SwD), but more gradually it is being proposed as a definitive treatment modality. However, the morbidity of this treatment for LC1 remains under-investigated. This study sought to determine the morbidities associated with IL as a treatment modality for LC1 and associated SwD.

METHOD

Single centre retrospective review of a prospective surgical database of one Pediatric Otolaryngologist at a tertiary care center. Participants included pediatric patients with an endoscopic diagnosis of LC1, treated with IL between 2000 and 2018-excluding those with concurrent upper airway anomalies. Patient charts were reviewed for demographic information, immediate post-op complications (within the first 14 days following IL), and subsequent management.

RESULTS

Out of 85 consecutive, eligible patients, 12 were excluded (5 subglottic stenosis, 6 laryngomalacia, and one tracheomalacia). Of the 73 included patients, 42 were male and 31 females. The median age at IL was 29 months (range 1-132, interquartile range of 38 months). All IL procedures in this study utilized hyaluronic acid derivatives. From this series, 13 patients experienced post-operative complications. The complications encountered were respiratory distress (N = 5), croup-like cough (N = 6), and stridor (N = 6). These complications were either self-limiting (N=9), managed by systemic or inhaled steroids (N = 4), or admitted to hospital for monitoring (N=3). One case (augmented with dextranomer and hyaluronic acid) required intubation, repeat endoscopy, and drainage of seroma.

CONCLUSION

IL was followed by respiratory morbidity in nearly two in ten of this series of consecutive patients. All the morbidities occurred in association with one injection product. Parents should be counselled appropriately about potential morbidities associated with this procedure.