Laryngeal Structural Dysphagia in Children

The upper aerodigestive system is closely intertwined from an embryologic and functional perspective. Laryngotracheal anatomic abnormalities, such as laryngomalacia, stenosis, vocal cord paralysis, and laryngeal clefts, affect not only the respiratory function but also the swallow function. Laryngotracheal pathology can interfere with the suck-swallow-breathe mechanism in infants. It can also exacerbate gastroesophageal reflux. Chronic aspiration secondary to laryngotracheal anomalies can result in respiratory and pulmonary complications. Surgical treatment of laryngotracheal anomalies can also cause transient or long-term swallow dysfunction. Multidisciplinary approaches and clinical assessment of swallowing are important in patients with laryngotracheal pathology.

Characteristics and outcomes of interventions for pediatric laryngomalacia: A systematic review with meta-analysis

OBJECTIVES

To analyze characteristics of children treated for laryngomalacia to determine predictive factors and provide an updated meta-analysis on outcomes.

METHODS

A systematic review was conducted according to PRISMA guidelines from inception to May 2, 2023, using CINAHL, PubMed, and Scopus databases. Study screening, data extraction, quality rating, and risk of bias assessment were performed by 2 independent reviewers. Data were meta-analyzed using fixed-/random-effects model to derive continuous measures (mean), proportions (%), and mean difference (Δ) with 95% confidence interval (CI).

RESULTS

100 articles were identified with information on outcomes of pediatric patients with laryngomalacia (N = 18,317). The mean age was 10.6 months (range: 0 to 252, 95%CI: 9.6 to 11.6, p = 0.00) with a 1.4:1 male to female ratio. Many patients presented with stridor (87.9%, 95% CI: 69.8 to 98.4), and the most common comorbidity at time of diagnosis was gastroesophageal reflux disease (48.8%, 95%CI: 40.9 to 56.8). Based on the patient population included in our analysis, 86.1% received supraglottoplasty (95% CI: 78.7 to 92.1). A total of 73.6% (95% CI: 65.5 to 81.0) had reported complete resolution of symptoms. For patients with a concurrent diagnosis of sleep disordered breathing receiving supraglottoplasty, the apnea-hypopnea index improved with a mean difference of -10.0 (95%CI: 15.6 to -4.5) events per hour post-treatment.

CONCLUSIONS

Laryngomalacia continues to be a common problem in the pediatric population. Supraglottoplasty remains an effective treatment option leading to symptomatic improvement in many cases. For those with concurrent sleep disordered breathing, supraglottoplasty lowers the apnea-hypopnea index.

Swallowing Function After Epiglottopexy in Children

OBJECTIVE

Epiglottopexy has been an increasingly utilized intervention in children with epiglottic prolapse and airway obstruction. Given the role of the epiglottis in protecting the airway during swallowing and the potential effect of repositioning the epiglottis on the passage of the bolus, we aimed to compare swallowing outcomes before and after epiglottopexy in children.

STUDY DESIGN

A retrospective cohort study.

SETTING

Tertiary care children's hospital.

METHODS

Data were extracted from charts of children who underwent epiglottopexy and had a subsequent instrumental swallowing evaluation between January 2018 and September 2022.

RESULTS

A total of 93 patients underwent epiglottopexy. Of these, 38 patients met inclusion requirements. The mean age at surgery was 41 ± 47 months. Most patients (n = 37, 97.4%) had significant comorbidities such as secondary airway lesions (n = 33, 91.7%), a genetic or syndromic disorder (n = 25, 69.4%), and dysphagia (n = 29, 76.3%). All patients had a concurrent procedure at the time of epiglottopexy with supraglottoplasty (n = 24, 63.2%) and lingual tonsillectomy (n = 16, 42.1%) being the most common. No changes in initiation or patterns of swallowing were noted postoperatively. A total of 7 (18.4%) patients had worsening swallow function: 2 had new-onset dysphagia, and 5 had worsening pre-existing dysphagia. Liquid or food textures penetrated remained unchanged or improved in most cases. No risk factors for worsening dysphagia were identified in our cohort.

CONCLUSION

Children with medical comorbidities undergoing epiglottopexy with additional airway interventions may experience new or worsening dysphagia. However, the procedure is generally safe without notable patterned changes in the swallowing mechanism.

Management of Persistent, Post-adenotonsillectomy Obstructive Sleep Apnea in Children: An Official American Thoracic Society Clinical Practice Guideline

Background: Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder. Although adenotonsillectomy is first-line management for pediatric OSA, up to 40% of children may have persistent OSA. This document provides an evidence-based clinical practice guideline on the management of children with persistent OSA. The target audience is clinicians, including physicians, dentists, and allied health professionals, caring for children with OSA. Methods: A multidisciplinary international panel of experts was convened to determine key unanswered questions regarding the management of persistent pediatric OSA. We conducted a systematic review of the relevant literature. The Grading of Recommendations, Assessment, Development, and Evaluation approach was used to rate the quality of evidence and the strength of the clinical recommendations. The panel members considered the strength of each recommendation and evaluated the benefits and risks of applying the intervention. In formulating the recommendations, the panel considered patient and caregiver values, the cost of care, and feasibility. Results: Recommendations were developed for six management options for persistent OSA. Conclusions: The panel developed recommendations for the management of persistent pediatric OSA based on limited evidence and expert opinion. Important areas for future research were identified for each recommendation.

Polysomnographic parameters and clinical risk factors predicting postoperative respiratory complications in children undergoing supraglottoplasty

STUDY OBJECTIVES

Postoperative respiratory complications (PORCs) can occur following supraglottoplasty (SGP) for obstructive sleep apnea. However, there are very limited data on risk factors associated with these complications. This study aims to evaluate the occurrence of PORC in children undergoing SGP and to assess clinical factors and polysomnographic parameters predicting these complications.

METHODS

A retrospective study was performed in children with laryngomalacia who underwent SGP with preoperative polysomnography.

RESULTS

400 children who underwent SGP met the criteria for entry into the analysis with a total of 416 surgeries with corresponding preoperative polysomnography. The median age (interquartile range) at the time of polysomnography was 0.4 (0.2, 1.5) years. A total of 96 (23.1%) PORCs were noted. Compared with those without complications, children with PORCs had a higher proportion of congenital heart disease (P < .05), higher median obstructive apnea-hypopnea index (obstructive AHI; median 16.0 vs 11.4 events/h; P < .01), and lower median oxygen saturation (SpO2) (P < .001). The unadjusted odd ratio indicated an increased risk of PORCs in children with congenital heart disease (odds ratio 1.66; P < .05) and those with an obstructive AHI > 10 events/h (odds ratio 2.06; P < .01). Multiple regression analysis demonstrated that an obstructive AHI > 10 events/h was the only independent risk factor for PORCs (P < .05).

CONCLUSIONS

In our cohort of children with laryngomalacia undergoing SGP, those with underlying congenital heart disease, higher obstructive AHI, and lower SpO2 were more likely to develop PORCs. Only children with an obstructive AHI > 10 events/h were at significantly increased risk for PORCs following SGP. Preoperative polysomnography is useful in preoperative planning in children undergoing SGP.

CITATION

Kanavitoon S, Ngamprasertwong P, Gurbani N, et al. Polysomnographic parameters and clinical risk factors predicting postoperative respiratory complications in children undergoing supraglottoplasty. J Clin Sleep Med. 2024;20(1):9-16.

Findings on drug-induced sleep endoscopy in infants with laryngomalacia

INTRODUCTION

Obstructive sleep apnea (OSA) is highly prevalent in infants with laryngomalacia (LM). Previous studies have reported high rates of persistent OSA following supraglottoplasty (SGP). The objective of this study is to describe the findings on drug-induced sleep endoscopy (DISE) in infants with LM.

METHODS

A retrospective review was performed including infants (12.5 months of age or less) with LM who underwent DISE along with direct laryngoscopy and bronchoscopy (DLB). Data collected included clinical presentation, swallow study results, sleep study results, past medical and surgical history, and postoperative outcomes when follow-up data was available. The findings on DISE as well as DLB were reviewed and described.

RESULTS

Thirty-five infants were included in the study with a mean age of 0.42 years (range 0.04-1.04). Obstructive sleep-disordered breathing (oSDB) and/or OSA were identified in 26 patients (74.3%) in addition to 7 patients (20%) with noisy breathing during sleep. DISE demonstrated LM in 31 patients (89%). DISE identified 12 patients (34%) with partial or complete obstruction at the level of the tongue base. DLB identified 14 patients (40%) with a secondary airway abnormality including 7 patients (20%) with type 1 laryngeal cleft and 4 patients (11%) with grade 1 subglottic stenosis. Eighteen patients (51%) underwent SGP.

CONCLUSION

DISE at the time of airway endoscopy for infants with LM can be helpful in identifying additional sites of obstruction including the tongue base. Glossoptosis may explain and/or predict the previously reported persistence of OSA following SGP. Additionally, DISE can complement awake flexible laryngoscopy in the assessment of severity of LM.

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.

Epiglottopexy in Infants Younger Than 6 Months Old: A Case Series

BACKGROUND

Severe laryngomalacia, characterized by apnea, hypoxia, and feeding difficulties, is an uncommon diagnosis that often requires surgical intervention with supraglottoplasty. Children who require surgery at a young age and those with additional comorbidities pose a special challenge and may require further surgical interventions. Posterior displacement of the epiglottis has been noted in some infants with congenital stridor and is commonly treated with epiglottopexy. The goal of our study is to review the outcomes of epiglottopexy combined with supraglottoplasty in our cohort of infants younger than 6 months old with severe laryngomalacia.

METHODS

A retrospective chart review of infants younger than 6 months old who underwent epiglottopexy combined with supraglottoplasty for severe laryngomalacia from January 2018 to July 2021 at a tertiary care children's hospital.

RESULTS

13 patients (age 1.3 week-5.2 months) underwent supraglottoplasty and epiglottopexy for severe laryngomalacia and epiglottis retroflection. The patients were admitted to the intensive care unit and remained intubated for at least one night. All patients demonstrated subjective and objective improvement in upper airway respiratory signs and symptoms. Ten patients demonstrated aspiration immediately postoperatively, despite 4 of them having no concern for aspiration at preoperative evaluation. On follow-up, 1 patient required revision supraglottoplasty and epiglottopexy for persistent laryngomalacia, and 2 patients required tracheostomy tube placement due to cardiopulmonary comorbidities.

CONCLUSION

Infants younger than 6 months old with medical comorbidities undergoing epiglottopexy with supraglottoplasty may demonstrate significant improvement in respiratory symptoms. Worsening dysphagia may complicate the postoperative period, particularly among children with medical comorbidities.

Prevalence and Management of Laryngomalacia in Patients With Pierre Robin Sequence

OBJECTIVE

To characterize the prevalence and presentation of laryngomalacia and efficacy of supraglottoplasty (SGP) in a cohort of patients with Pierre Robin Sequence (PRS).

DESIGN

Retrospective cohort study.

SETTING

Tertiary-care children's hospital.

PATIENTS, PARTICIPANTS

Consecutive patients with PRS born between January 2010 and June 2018.

MAIN OUTCOME MEASURES

Chart review included demographics, comorbid airway obstruction including laryngomalacia, timing of surgical interventions, clinical symptoms, sleep study data, and modified barium swallow study data.

126 patients with PRS were included; 54% had an associated syndrome, 64% had an overt cleft palate, and 22% had a submucous cleft palate. 64/126 were noted to have laryngomalacia (51%). Patients with concurrent PRS and laryngomalacia were significantly more likely to have submucous cleft palate (P = .005) and present with aspiration with cough (P = .01) compared to patients with PRS without laryngomalacia. Patients with concurrent laryngomalacia and PRS showed a significant decrease in apnea-hypopnea index (AHI) and obstructive AHI (OAHI) after mandibular distraction, with a median AHI and OAHI improvement of 22.3 (P = .001) and 19.8 (P = .002), respectively. Patients who underwent only SGP did not show significant improvement in these parameters (P = .112 for AHI, P = .064 for OAHI).

The prevalence of laryngomalacia in our PRS cohort was 51%. Patients with PRS and laryngomalacia are more likely to present with overt aspiration compared to patients with PRS without laryngomalacia. These data support that laryngomalacia does not appear to be a contraindication to pursuing MDO.

Features and Associated Comorbidities of Laryngomalacia in Saudi Arabia

Laryngomalacia (LM) is defined as the collapse of supraglottic structures during inspiration, resulting in intermittent airflow impedance and associated stridor. LM is the most prevalent cause of congenital stridor in newborns. The aim of this study is to determine the features and associated comorbidities of LM in Saudi Arabia and to delineate the diagnostic and therapeutic measures used, based on the severity of the case and related comorbidities. This is a three-year retrospective study of children diagnosed with LM and treated in the pediatric otorhinolaryngology outpatient clinic at Maternity and Children Hospital, Dammam, Saudi Arabia, between January 2018 and January 2022. The inclusion criteria were patients with signs and symptoms of LM who are younger than 14 years old. The diagnosis of LM was based on clinical evaluation and confirmed by nasopharyngolaryngoscopy in awake patients and/or direct laryngoscopy and scoping under general anesthesia with spontaneous ventilation for dynamic evaluation. The Olney classification was used for the morphological classification of LM. The exclusion criteria were patients lost to follow-ups. Follow-up duration was two years minimum. A total of 52 patients were included in the study. Among the participants, females accounted for 71% and males accounted for 29% of cases. Our results were in accordance with the relevant literature, except for the higher prevalence of LM in full-term neonates who were found to account for 69.2% of the cases. Understanding the patterns and characteristics of breathing may help clinicians distinguish the noisy breathing of LM from other illnesses because infants are frequently misdiagnosed with these conditions.

An Analysis of Laryngomalacia and Its Interplay With Obesity and Obstructive Sleep Apnea in Pediatric Inpatients

Objective  This study aimed to investigate the potential relationship between laryngomalacia and obesity as well as explore the interplay between laryngomalacia and obstructive sleep apnea using the Kids' Inpatient Database (KID) for the year 2016. Methods The Healthcare Cost and Utilization Project (HCUP) KID for 2016 provided a dataset for analysis. Patient demographics, diagnoses, and hospital characteristics were considered. Patients less than three years old were included due to the high prevalence of laryngomalacia in this age group. Results Among 4,512,196 neonatal admissions, 1,341 obesity cases and 11,642 laryngomalacia cases were analyzed. The frequency of laryngomalacia in patients with obesity was 578.1% higher than in the general population. Patients with obstructive sleep apnea (OSA) exhibited a 5,243.2% increase in laryngomalacia frequency compared to the overall population. Combining obesity and laryngomalacia resulted in a 6,738.5% increase in OSA frequency. Conclusions This study identified a significant correlation between obesity and increased laryngomalacia risk. The findings have important clinical implications for pediatric care, emphasizing the need to prevent childhood obesity to reduce laryngomalacia risk. Additionally, understanding these risk factors enables better risk stratification for laryngomalacia and potential OSA development.

Implications of traumatic unilateral aryepiglottic fold injury on swallowing: A case series

OBJECTIVE

This retrospective case series examines the effect of traumatic unilateral aryepiglottic fold injury on swallowing and airway protection. It focuses on the longitudinal care of five pediatric patients to determine the dietary modifications required to maintain a safe, functional swallow.

METHODS

Retrospective chart review of patients with a diagnosis of unilateral aryepiglottic fold injury was performed. Cases were clinically identified by pediatric otolaryngologists at a single quaternary care pediatric hospital upon operative endoscopic evaluation. Clinical swallow outcomes were measured with the Rosenbek Penetration Aspiration Scale.

RESULTS

Average age at diagnosis was 10 months with mean follow-up of 30 months. Eighty percent of patients were female. All patients had right-sided aryepiglottic fold injuries. Four patients were intubated for an average of 3 months and a fifth patient had a traumatic intubation event. All currently take nutrition by mouth, albeit to varying degrees. Four patients adequately protect their airway from aspiration with all oral consistencies. Optimized delivery of thin liquids yielded a Rosenbek penetration aspiration scale (PAS) score of 1 in four patients and 4 in the remaining patient. Four patients required gastric tube placement during severe illness, and three remain partially dependent. Surgical correction was attempted for one patient without improvement.

CONCLUSION

Based on a limited and somewhat heterogeneous case series, the data suggests that traumatic unilateral aryepiglottic fold injury does not prohibit oral intake in most cases. While the PAS score under optimized conditions is impressive, implications for a safely tolerated diet remain. There is sparse published literature upon this topic, and the longitudinal data presented may serve as a pilot study for future investigation by shedding light on the consequences of this airway injury.

Surgical Candidacy for Management of Laryngomalacia: A Proposed Scoring System

Introduction

Identifying surgical candidacy for the management of laryngomalacia is a challenge.

Objective

To develop a simple scoring system for surgical candidacy in laryngomalacia.

Methods

Eighteen years retrospective observational study of children with laryngomalacia (LM) clinically categorized into mild, moderate and severe LM and were analyzed for surgical candidacy.

Results

There were 113 children (age ranging from 5 days to 14 months), 44% being mild, 30% moderate and 26% severe LM. None in mild, 32% in moderate, and all in severe LM had surgical intervention. Presence of stridor on feeding or crying and isolated type 1 or type 2 LM on laryngoscopy were significant indicators for conservative treatment (p-< 0.0001). Moderate failure to thrive, retraction at rest/sleep, with low oxygen saturation while feeding/at rest were significantly higher in both moderate and severe groups with laryngoscopic evidence of combined type 1 and 2 in moderate LM (p < 00,001). Aspiration pneumonia, hospitalization, pectus and mean pulmonary arterial pressure of more than 25 mmHg with laryngoscopic findings of all three combined types were significantly higher in severe LM (p < 0.0001).A simple scoring system was then developed and it revealed that a score of 10 or more required surgical intervention.

Conclusion and clinical significance

A clinical scoring system is being reported for the first time in medical literature to identify 'the difficult to treat' subset within moderate laryngomalacia category simplifying decision making in its management for otolaryngologists and pediatricians as well as a referral criterion for pediatric otolaryngologists' services.

Long term Follow Up of Severe Laryngomalacia Patients Following CO2 LASER Supraglottoplasty

Laryngomalacia is the most common cause of stridor. It is believed to be due to delayed development of the supraglottic structures. On the basis of presentation, it has been divided into 3 grades. Management is dependent upon the grades: Mild and moderate laryngomalacia are managed conservatively, while CO2 LASER supraglottoplasty is the surgical management of choice for severe disease. In this study we evaluated the outcomes of supraglottopasty in long term follow up. It was a retrospective study which included patients with severe laryngomalacia who have undergone supraglottoplasty for the dates from July 2013 to July 2018. Weight and height of the patients were taken during the follow up visit after one year and have been compared with that of the normal children of comparable age using the pediatrics growth charts. Follow up was done by telephonic conversation to evaluate the status of other symptoms associated with laryngomalacia. Total of 44 patients were included in the study, 47.7% and 52.3% females and males respectively. Weight for age, weight for height and height for age were normal in 80.9%, 80.9% and 76.1% of patients respectively after supraglottoplasty. Of the patients studied, stridor was resolved in 80.9%, early tiredness during play was resolved in 43.2%, swallowing was normal in 85.7% and there was no aspiration in 90.5%. It can be concluded that patients with severe laryngomalacia improved with respect to airway symptoms, as well as, weight and height on long term follow up after CO2 LASER supraglottoplasty. It is important to evaluate the general status of the patients as a whole to truly assess the success of the surgery in addition to the airway symptoms.

Management of Stridor in Severe Laryngomalacia: A Review Article

Laryngomalacia is the term most broadly used to portray the "internal breakdown of structures of supraglottis of the larynx at the time of inspiration. It is often associated with stridor during inspiration, which is of a high pitch at the time of birth and comes into notice by 14 days. When there is an increase in breathing, stridor worsens, and it is usually position-dependent. Laryngomalacia means the weakening of the larynx resulting in a collapse of the laryngeal cartilages, especially the epiglottis, into the airway. This partially occludes the upper airway during inspiration and causes inspiratory stridor. The exact etiology of the condition is not known. It is a well-known cause of noisy breathing in neonates and infants. The common presentation is a neonate with flushing and high-pitched inspiratory stridor that is usually noticed before 14 days of age. This worsens with breathing and supine positioning and improves in a prone position. Less commonly, it can present with hypoxia, feeding problems, aspiration, and failure to thrive. The condition may increase in severity during early life but usually self-resolves by two years of age. The hiccup-like squeak of laryngomalacia during inspiration is due to unsettled air flowing through the laryngeal passage. The condition is diagnosed with laryngoscopy, and the treatment varies with presentation and severity. Neonates with the uncomplicated disease can be treated expectantly. Those presenting with feeding problems and gastroesophageal reflux will require acid suppression. Severe complications like aspiration, severe airway obstruction, and hypoxia will require surgical treatment, including supraglottoplasty. In cases where the surgical treatment failed, noninvasive ventilation can be advised. The article reviews the various medical and surgical interventions and the management of severe laryngomalacia.

Pediatric Dysphagia

Feeding difficulty is common in the pediatric population, particularly in at-risk infants, such as those born prematurely. Appropriate work-up should involve a multidisciplinary team and may commonly use modified barium swallow and flexible endoscopic evaluation of swallow, in addition to history and physical examination. Structural causes of dysphagia may involve surgical management, whereas nonstructural causes may invoke medical therapies. If symptoms do not resolve following intervention, it is important to revisit the interdisciplinary team, because dysphagia is commonly multifactorial in origin. Appropriate identification and early intervention are necessary for successful outcomes in growth and development for children.

[Analysis of clinical characteristics and surgical efficiency of severe laryngomalacia in children]

Objective:To analyze the clinical characteristics and factors affecting surgical efficiency in children with severe laryngomalacia. Methods:Retrospectively collect medical records of children with severe laryngomalacia who underwent supraglottoplasty in Children's Hospital of Chongqing Medical University between January 1, 2015 and May 1, 2019. And analyze the clinical characteristics, the improvement of main symptoms at different time points, and the influence factors on the surgical efficiency. Results:According to the anatomical classification of severe laryngomalacia, type Ⅳ accounted for the highest proportion（66.1%）, and type Ⅰ was the lowest（3.6%）. All children had stridor and dyspnea, 82.1% cases presented feeding difficulties, and 67.9% cases presented failure to thrive. The proportion of children with medical comorbidities was 62.5%, of which congenital heart disease had the highest incidence（39.3%） The surgical efficiency of severe laryngomalacia without comorbidities was 100.0%, with one type of comorbidity was 96.0%, with multiple comorbidities was 30.0%（P<0.01）. Stridor, dyspnea, feeding difficulties were significantly improved at one month after surgery in most cases. In the group of surgical age less than 3 months, the surgical efficiency were 61.5%, 61.5% and 69.2% at 1, 3, 6 months after surgery, respectively; the surgical efficiency of children without comorbidities were 100.0%（P>0.05） at 1, 3 ,6 months after surgery. In the group of surgical age older than 3 months, the surgical efficiency of children were 100.0% at 1, 3, 6 months after surgery regardless with or without comorbidities. The surgical failure rate and reoperation rate in children without comorbidities was 0, but in the children with comorbidities were 22.9%（P<0.05） and 20.0%（P<0.05）, respectively. The surgical failure rate and reoperation rate in children with multiple comorbidities was significantly higher than children with only one comorbidity（70.0% vs. 4.0%; 60.0% vs. 4.0%, P<0.01）. The overall operation success rate was 85.7% in severe laryngomalacia children in our hospital. Conclusion:Most children with severe laryngomalacia are associated with multiple medical comorbidities, and with more complex anatomical types. Supraglottoplasty can effectively improve the symptoms in most children with severe laryngomalacia. The existence of multiple comorbidities is the main cause of surgical failure.

Implementation of Pediatric Flexible-Endoscopic Evaluation of Swallowing: A Systematic Review and Recommendations for Future Research

BACKGROUND

Although pediatric flexible-endoscopic evaluation of swallowing (FEES) has developed into a standard in dysphagia diagnostics, there are no valid protocols and procedures for children available to date.

OBJECTIVE

This systematic PROSPERO-registered review aimed to identify implementation protocols for pediatric FEES described in research studies, and to analyze them in detail concerning procedural steps, equipment, and reported outcome.

METHODS

Included were all studies reporting a pediatric FEES protocol for children aged 0-18 years, if they described at least two criteria defined in advance. The databases MEDLINE and CINHAL were searched systematically from January 2000 to February 2021. Risk of bias for included studies was assessed using the National Institutes of Health (NIH) quality assessment tool for observational cohort and cross-sectional studies. A narrative synthesis of the FEES protocols was conducted and the results compared in tabular form.

RESULTS

In total 22 studies were included, reporting on FEES in 1547 infants, children, and adolescents with a wide range of diagnoses. It was possible to identify protocols related to all age groups in general as well as to particular groups such as breastfed or bottle-fed infants. None of the included studies demonstrated a good methodological quality; all studies had missing data. Uniform implementation for sub-groups could not be determined. The reported outcome of FEES examinations could not be compared.

DISCUSSION

None of the included studies showed good methodological quality and a significant amount of data were missing; the review still offers a systematic basis for future research to close the serious gap in the area of pediatric FEES. A proposal is made for a minimum requirement for pediatric FEES protocols in scientific studies.

Acid Suppression Does Not Improve Laryngomalacia Outcomes but Treatment for Oropharyngeal Dysphagia Might Be Protective

OBJECTIVE

To determine whether the use of acid suppression and thickened feeds impact laryngomalacia outcomes in infants, including supraglottoplasty risk, time to supraglottoplasty, and hospitalization risk.

STUDY DESIGN

We performed a retrospective cohort study to compare risk and time with supraglottoplasty and frequency and duration of hospitalizations for infants diagnosed with laryngomalacia at Boston Children's Hospital between January 1 and December 31, 2017. The primary outcomes were supraglottoplasty requirement, time to supraglottoplasty, and hospitalization risk. Multivariate analyses were performed to determine predictors of supraglottoplasty and hospitalization risk after adjusting for laryngomalacia severity and comorbidities in addition to propensity score adjustment. Kaplan-Meier curves were created to determine the impact of acid suppression use on time to supraglottoplasty.

RESULTS

In total, 236 subjects with mean age 62.6 ± 4 days were included in the analysis; 55% were treated with acid suppression. Subjects treated with acid suppression had a greater risk of supraglottoplasty (hazard ratio 3.36, 95% CI 1.36-8.29, P = .009), shorter time to supraglottoplasty (5.64 ± 0.92 vs 7.98 ± 1.92 months, P = .006), and increased respiratory hospitalization risk (relative risk 1.97, 95% CI 1.01-3.85, 0.047), even after adjustment for covariates. Subjects receiving thickening had fewer respiratory hospitalization nights and longer time to supraglottoplasty (9.3 ± 1.7 vs 4.56 ± 0.73 months, P = .004), even after adjustment.

CONCLUSIONS

Acid suppression use does not reduce the frequency of supraglottoplasty and related hospitalizations compared with untreated subjects. However, patients treated with thickening have decreased hospitalization and longer time to supraglottoplasty, suggesting that thickening of feeds may be a preferred intervention over acid suppression.

Coblation supraglottoplasty: a ten-year experience in a tertiary referral hospital

PURPOSE

The present study aims to review the outcomes of coblation supraglottoplasty performed for children with different types of laryngomalacia, and we discuss the factors affecting these outcomes.

METHODS

We retrospectively reviewed the medical records of laryngomalacia patients admitted to the Otorhinolaryngology Department, Mansoura University, from 2010 to 2020. We examined the patient's demography, symptoms, comorbidities, type of laryngomalacia, oxygen saturation, and final outcomes.

RESULTS

Our study included 235 patients; 122 patients responded to medical therapy, while 113 underwent surgical management. There is a significant relation between the types and therapy they underwent (p ≤ 0.001). Larger percentage within type I underwent medical therapy. There is a statistically significant difference between the studied groups regarding age at surgery. On pairwise comparison, patients with type II had the lowest age significantly at the surgery when compared with each other individual group (p ≤ 0.001). On multivariate regression analysis, the presence of comorbid congenital heart disease, neurological comorbidities significantly increased the risk of failure of surgical intervention by 17.32 and 5.803 folds, respectively.

CONCLUSIONS

Coblation supraglottoplasty is effective and safe to treat severe laryngomalacia. Different morphological types of laryngomalacia require slight surgical variations of coblation supraglottoplasty. The presence of comorbid congenital heart disease, neurological comorbidities significantly increased the risk of failure of surgical intervention.

Swallowing Outcomes Following Supraglottoplasty: A Retrospective Review

OBJECTIVES/HYPOTHESIS

Determine the incidence of short- and long-term dysphagia in pediatric patients with and without syndromes/neurodevelopmental delay following supraglottoplasty (SGP) at our institution.

STUDY DESIGN

Retrospective cohort study.

METHODS

A retrospective cohort study of children ≤18 years old who underwent SGP from 2014 to 2019 was undertaken. Age at surgery, sex, race, insurance, underlying syndromes/neurodevelopmental delay, concurrent surgical procedures, and clinical swallowing assessments were reviewed. Logistic regression was performed to identify factors associated with postoperative feeding difficulties. Time-to-event analysis was performed to assess time to resolution of dysphagia.

RESULTS

A total of 231 patients were identified. Average age at time of SGP was 13.7 months. Of 231 patients, 88 (38.1%) had a syndrome/neurodevelopmental delay. Of these 231 patients, 112 had a preoperative videofluoroscopic swallow study or fiberoptic endoscopic evaluation of swallowing, of whom 53/112 (47.3%) had dysphagia. After SGP, 138/231 (59.7%) underwent clinical/instrumental swallowing assessments, of whom 95/138 (68.8%) had immediate postsurgical dysphagia. At last follow-up (1 month to 45 months), 15/95 (15.8%) had persistent dysphagia on instrumental assessment, 14/15 of whom had syndromes/neurodevelopmental delay. Time-to-event analysis revealed that for the nonsyndromic cohort, 25% had resolution of dysphagia by 4 months, 50% by 10 months, and 75% by 14 months. Cox proportional hazards regression revealed that the presence of underlying syndromes/neurodevelopmental delay was the only factor predictive of long-term postoperative dysphagia (hazard ratio of resolution 0.21 [95% confidence interval 0.096-0.48]).

CONCLUSIONS

While short-term feeding difficulties following SGP in pediatric patients are not uncommon, long-term dysphagia is rare in patients without syndromes/neurodevelopmental delay. These data can be used when counseling caregivers about the risks and benefits of SGP.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

Supraglottoplasty in the management of laryngomalacia in children with down syndrome: A systematic review

INTRODUCTION

Children with Down syndrome (DS) who have Laryngomalacia represent a specific management challenge due to their inherent multiple levels of airway obstruction and hypotonia. Therefore, the purpose of this study is to determine the outcome of supraglottoplasty (SGP) in children with DS.

DATA SOURCE

A systematic review was performed following the PRISMA guideline. Data were collected from online medical databases- CINAHL, Cochrane Library, Google Scholar, Ovid MEDLINE, Ovid MEDLINE in process, PubMed, and Scopus.

REVIEW METHODS

all publications that address the outcome of supraglottoplasty in children who are less than 18 years old with Down syndrome prior to December 2018 were collected. The data were collected on different phases: Screening review using search words and controlled vocabularies during the period of November-December 2018, followed by a detailed review of screened articles based on inclusion and exclusion criteria, then a full review that included screening the references of selected articles.

RESULTS

Nine articles were included in the qualitative analysis. These articles included 231 subjects, out of which 32 children with DS met the inclusion criteria. Twenty patients (62.5%) were considered successfully treated and 12/32 failed including 1/32 (3.1%) mortality in the postoperative period. The duration of follow-up was 12-102 days. All of the patients whose treatment failed had significant comorbidities.

CONCLUSION

Although the success of SPG in children with DS is less than in otherwise healthy children, it remains an option especially in patients without comorbidities. Preoperative counseling of the families and thorough assessment are necessary to determine candidacy for SPG in children with DS.

Flexible Endoscopic Evaluation of Swallowing in Breastfeeding Infants With Laryngomalacia: Observed Clinical and Endoscopic Changes With Alteration of Infant Positioning at the Breast

OBJECTIVES

This retrospective cohort study uses endoscopic assessment of the pharyngeal phase of swallowing in infants with laryngomalacia, to ascertain the impact of infant positioning on airway compromise and fluid dynamics during breastfeeding. The study aims to identify whether modification of infant positioning at the breast may improve the possibility of safe, successful breastfeeding in infants with laryngomalacia and concurrent breastfeeding difficulty.

METHODS

Twenty-three infants referred for noisy breathing and difficulty feeding were assessed with flexible endoscopic evaluation of swallowing (FEES) during breastfeeding. All had endoscopically confirmed laryngomalacia. During FEES, observations were made of clinical signs of airway compromise as well as endoscopically observable anatomical features and swallowing dynamics during breastfeeding, including tongue base position, view of laryngeal inlet and vocal folds, dynamic supraglottic soft tissue collapse, timing of milk flow into pyriform fossae/hypopharynx relative to sucking, and presence of penetration and/or aspiration. If airway and/or swallowing compromise was present, the infant's initial position at the breast was altered from supine or semi lateral decubitus position to semi-prone, with a description of the clinical and endoscopically observable changes that subsequently occurred.

RESULTS

Signs of dynamic airway obstruction and/or compromised airway protection with swallowing were present in 20 of the 23 infants (87%) in their initial supine or semi lateral decubitus position. These 20 infants were repositioned to semi-prone, with improvement and/or resolution of stridor and an improved ability to maintain latch in all infants. Continued endoscopic evaluation following positional change was possible in 16 infants, identifying anterior positioning of the tongue base, reduced dynamic supraglottic tissue collapse, reduced volume of milk flow into pyriform fossae during pauses in sucking and resolution of penetration and aspiration.

CONCLUSION

This study has shown how alteration of breastfeeding position to semi-prone may improve dynamic airway obstruction and reduce aspiration risk in infants with laryngomalacia.

Surgical Intervention for Laryngomalacia: Age-Related Differences in Postoperative Sequelae

OBJECTIVE

Identify risk factors and determine perioperative morbidity of children undergoing surgery for laryngomalacia (LM).

METHODS

A retrospective analysis of the multi-institutional American College of Surgeons National Surgical Quality Improvement Program-Pediatric Database (ACS-NSQIP-P) was performed to abstract patients aged <18 years with LM (ICD-10 code Q31.5) who underwent laryngeal surgery (CPT code 31541) from 2015 to 2017. Analyzed clinical variables include patient demographics, hospital setting, length of stay, medical comorbidities, postoperative complications, readmission, and reoperation.

RESULTS

A total of 491 patients were identified, 283 were male (57.6%) and 208 were female (42.4%). The mean age at time of surgery was 1.07 years (range .01-17 years). Younger patients were more likely to undergo surgery in the inpatient setting compared to their counterparts (P < .001). Infants were more likely to have prolonged duration of days from admission to surgery (P < .001), days from surgery to discharge (P < .001), and total length of stay (P<.0010). Finally, there was no significant difference between age groups with respect to 30-day general surgical complications (P = .189), with an overall low incidence of reintubation (1.2%), readmission (3.1%), and reoperation (1.6%).

CONCLUSION

This analysis supports laryngeal surgery as a safe surgical procedure for LM. However, younger children are more likely to undergo operative intervention in the inpatient setting, endure delays from hospital admission to surgical intervention, and experience a prolonged length of stay due to their overall medical complexity. Recognition of key factors may assist in optimizing perioperative risk assessment and promote timely procedural planning in this unique pediatric patient subpopulation.

Evaluation of Aspiration in Infants With Laryngomalacia and Recurrent Respiratory and Feeding Difficulties

Importance

Laryngomalacia is the most common laryngeal anomaly and is commonly associated with stridor in children, but the recurrent respiratory and/or feeding difficulties associated with this condition may pose a threat to the well-being of the affected child.

Objective

To describe the prevalence of aspiration in pediatric patients with laryngomalacia who present with recurrent respiratory issues and/or feeding difficulty.

Design, Setting, and Participants

This retrospective review of medical records involved 142 pediatric patients. These patients received a laryngomalacia diagnosis, presented with recurrent respiratory and/or feeding difficulties, and underwent a modified barium swallow (MBS) study at a tertiary referral children's hospital from January 1, 2015, to December 31, 2015. Each patient was assessed for aspiration and swallowing discoordination. Data collection and analysis were performed from December 1, 2016, to September 30, 2017.

Main Outcomes and Measures

Demographic data, presenting symptoms, medical comorbidities, and feeding and dysphagia details were collected and analyzed. Speech-language pathologists reviewed all MBS reports to identify the presence and type of aspiration (ie, silent vs nonsilent) with different textures and consistencies of food and liquid.

Results

A total of 395 patients were diagnosed with laryngomalacia in 2015. One hundred forty-two of these patients (35.9%) presented with recurrent respiratory issues and/or feeding difficulties and were referred for MBS study for further evaluation. Ninety-two (64.8%) were male, with a median (interquartile range) age at the time of MBS study of 7.9 (3.2-20.5) months. Among these patients, 128 (90.1%) had swallowing dysfunction documented during the MBS study. Aspiration was identified in 60 patients (42.3%), and silent aspiration was documented in 59 (98.3%) of these 60 patients. Epilepsy or seizures (risk difference [RD], 11%; 95% CI, 5%-17%), laryngeal cleft (RD, 8%; 95% CI, 3%-13%), and premature birth (RD, 15%; 95% CI, 5%-25%) were statistically significantly associated with abnormal MBS findings.

Conclusions and Relevance

Swallowing dysfunction and aspiration were commonly found in pediatric patients with laryngomalacia and recurrent feeding and/or respiratory issues; these children should undergo an MBS study for dysphagia and silent aspiration.

Routine admission to step-down unit as an alternative to intensive care unit after pediatric supraglottoplasty

OBJECTIVE

To evaluate the feasibility and the outcomes for step-down (SD) unit admission as an alternative to intensive care unit (ICU) admission after supraglottoplasty in the pediatric patient.

METHODS

A review of 98 patients who underwent supraglottoplasty from 2012 to 2017 at a tertiary referral pediatric hospital was performed. An SD unit had 1-to-3 nurse-to-patient ratio with noninvasive positive pressure ventilation capability. Data variables included demographics, comorbidities, preoperative and postoperative respiratory requirements, and length of stay.

RESULTS

Routine admission to SD occurred for 85% patients while 15% patients were selectively admitted to ICU due to intubation requirement or perioperative respiratory distress. In SD, noninvasive respiratory support was required for 28 (34%) patients. Three (4%) required re-intubation and ICU transfer without delay in care. Patients at high risk for requiring respiratory support after surgery have a neurologic condition (OR 7.0, 95% 2.4-20.2, p < 0.01) or intrinsic pulmonary disease (OR 4.5, 95% CI 1.5-13.3, p < 0.01). Median length of stay was shorter for patients in step-down (1 day, IQR 1-2).

CONCLUSION

Patients can be managed safely in a SD unit after supraglottoplasty supporting de-escalation of care. Patients with neurologic and pulmonary comorbidities may have higher respiratory needs postoperatively. Prospective studies are warranted to further optimize resource allocation.

Aspiration and Dysphagia in the Neonatal Patient

Dysphagia and aspiration are commonly encountered problems in the neonatal population. It is often multifactorial in nature and management should be tailored to the individual patient. Multiple causes should be considered, including anatomic abnormalities, neurologic/developmental delay, cardiopulmonary disease/infection, and gastroesophageal reflux disease, in addition to those cases where a definitive reason may not be identified. Management should be multidisciplinary in nature and surgical intervention may be indicated in certain populations of patients. Here, we discuss the presentation, workup, and management of the neonatal patient with dysphagia and aspiration.

Supraglottoplasty in children with laryngomalacia: A review and parents' appraisal

PURPOSE

To assess the parents' perspective concerning the children's clinical picture before and after supraglottoplasty for the treatment of laryngomalacia (LM).

MATERIALS AND METHODS

Retrospective study in 110 children diagnosed with LM followed at the Pediatric Otorhinolaryngology outpatient clinics of S. João Hospital Center, between 2008 and 2016. Children who underwent supraglottoplasty were reviewed in terms of demographics, symptoms, comorbidities, treatment and follow-up. Parents were interviewed and filled out a structured questionnaire designed to evaluate their perception of the child's clinical picture and their degree of comfort before and after surgery.

RESULTS

Thirty-one children (28,2%) underwent supraglottoplasty at a median age of 6 months-old. Twelve patients had one or more medical comorbidities. Stridor was present in all children on the pre-operative period and resolved in 92,3% of the cases after supraglottoplasty; shortness of breath persisted in 3,8% in contrast to the previous 57,7%; and feeding difficulties remained in 15,4% children against the 65,4% before the procedure. Failure in thriving was also a pre-operative complaint, that recovered as reported by parents in all children after supraglottoplasty. No surgical complications were reported, and the median hospital stay was two days. In a 0 to 10 points scale, the median level of the parents' comfort with their child's clinical picture before supraglottoplasty was one point which was significantly worse than the mean level of ten points after surgery (p < 0.001).

CONCLUSIONS

In severe cases, LM can have a strong negative impact on family dynamics and functioning. In selected cases, supraglottoplasty can be a safe and effective treatment option which is associated with a high degree of parental satisfaction.

Impact of supraglottoplasty on parental preception of swallowing using a 10 question swallowing index

INTRODUCTION

Laryngomalacia can have a significant impact on swallowing function. Most of the studies in literature have focused on evaluating swallowing dysfunction in children with Laryngomalacia using clinical assessment and swallowing studies i.e. functional endoscopic evaluation of swallowing or videofluroscopic evaluation of swallowing.

OBJECTIVE

The objective of the current study was to evaluate the parental perception of swallowing using a newly devised 10-point swallowing index before and after supraglottoplasty.

MATERIAL AND METHODS

This was a prospective study performed at a tertiary care Aerodigestive center over a period of 18 months. A total of 51 supraglottoplasties were performed by a single surgeon over an 18-month period. Parents were asked to fill a non validated 10-point questionnaire before and after supraglottoplasty. Of the 51 surgeries, 34 surveys were completed, and 28 surveys were included in the study. All the patients were classified in to mild, moderate and severe laryngomalacia based on the established criterion. Each point in the index was graded on the Likert scale.

RESULTS

A total of 28 patients who underwent supraglottoplasty were included in the study. There was a significant improvement in the overall parental perception in the swallowing of children with laryngomalacia following supraglottoplasty. There was statistically significant improvement in 9 out of 10 indices on the questionnaire.

CONCLUSION

Supraglottoplasty has an overall positive impact on parental perception of swallowing in children with Laryngomalacia. Caregivers had fewer concerns postoperatively, with fewer choking spells and breathing issues during feeds, and a greater satisfaction with the amount consumed at each feed. This Index adds a valuable subjective component to pediatric swallowing assessments pre and post supraglottoplasty. This tool could be used in conjunction with MBSS and FEES measures to provide a more comprehensive assessment.

A novel technique for unilateral supraglottoplasty

OBJECTIVES

Traditional supraglottoplasty for pediatric laryngomalacia is most commonly conducted with either CO2 laser or cold steel instruments. While the procedure enjoys high success rates, serious complications such as excessive bleeding, supraglottic stenosis and aspiration can occur. Unilateral coblation supraglottoplasty may reduce this risk, but data on respiratory and swallowing outcomes are lacking. This study reports our experiences with unilateral coblation supraglottoplasty.

METHODS

Pediatric patients with severe congenital laryngomalacia who underwent unilateral supraglottoplasty at a single institution from 2013 to 2016 were retrospectively reviewed. Bipolar radiofrequency ablation (Coblation) was utilized with partial arytenoidectomy, aryepiglottoplasty, and advancement of mucosal flaps. Outcome measures included apnea-hypopnea index (AHI), weight-by-age percentile, and decannulation rate.

RESULTS

Twelve patients were included with an average age of 13.1 months (range 2-28 months). In patients without tracheostomy, 88% had complete resolution of respiratory symptoms, while the remainder had significant improvement. In patients without gastrostomy tubes, there was an average increase in weight-age percentile of 6.1, 7.8, and 15.3 points at 1, 3, and 6 months postoperatively, respectively. Three patients had complete polysomnography data with a mean preoperative AHI of 19.3 and postoperative AHI of 4.0. Three of four patients with tracheostomy have been decannulated at a mean follow-up of 1.5 years. There were no early or late postoperative complications and no revision supraglottoplasty.

CONCLUSION

Unilateral supraglottoplasty with bipolar radiofrequency ablation can improve respiratory symptoms and decrease OSA severity in severe congenital laryngomalacia. This technique is safe and can lead to substantial improvement in AHI in patients with OSA.

Laryngomalacia: is there an evidence base for management?

Background:

The advent of supraglottoplasty clearly has transformed the surgical management of severe laryngomalacia. The condition, however, generally runs a milder course, with spontaneous resolution the norm.

Objectives:

To identify gaps in the knowledge and identify topics for future study.

Method:

Systematic review of the literature.

Results:

The literature suggests that there is a range of abnormalities leading to the typical collapsing upper airway, and that neurological disease, other airway abnormalities, syndromes and gastroesophageal reflux all contribute to disease severity and influence outcomes. The procedures involved in supraglottoplasty are rarely specified, the indications for surgery are vaguely defined and the role of medical therapy is unclear.

Conclusion:

Every review article or survey of opinion suggests that there is still a marked variation in individual practice and a lack of consensus.

Predictors for routine admission to paediatric intensive care for post-supraglottoplasty laryngomalacia patients

Objectives:

Supraglottoplasty for the treatment of laryngomalacia has little current evidence regarding post-operative care. Our study aimed to: (1) retrospectively assess what proportion of patients required paediatric intensive care unit level of care; (2) identify pre-operative predictive factors common to these cases; and (3) report patient outcomes at six weeks’ follow up.

Methods:

A 10-year retrospective case series analysis was conducted of all patients diagnosed with laryngomalacia and subsequently treated with supraglottoplasty. Paediatric intensive care unit level of care was defined as the need for intubation or tracheostomy, positive pressure ventilation, multiple doses of nebulised adrenaline, and oxygen dependency beyond 12 hours.

Results:

Forty-two patients (19 males, 23 females) were identified; 28.5 per cent of cases met our criteria for paediatric intensive care unit level of care. A low pre-operative oxygen saturation was the only significant risk factor that predicted a future need for paediatric intensive care unit level of care (p = 0.0008).

Conclusion:

This is the first study published in the UK to suggest the importance of pre-operative oxygen saturation as a predictor of a future need for paediatric intensive care unit level of care.

Accuracy of clinical swallowing evaluation for diagnosis of dysphagia in children with laryngomalacia or glossoptosis

OBJECTIVE

To investigate the accuracy of clinical evaluation of swallowing in a sample of children with laryngomalacia or glossoptosis and describe the prevalence of dysphagia in each of these diseases, as well as characterize the swallow response to speech and language therapy interventions.

STUDY DESIGN

Children aged 1 month to 11 years receiving care at the Department of Otolaryngology, Hospital de Clínicas de Porto Alegre, Brazil, were evaluated in a cross-sectional design. Evaluation of swallowing was performed at two time points by two blinded speech-language pathologists, one responsible for clinical evaluation and the other for videofluoroscopic study. The protocols employed were based on the instruments proposed by DeMatteo et al. (DeMatteo C, Matovich D, Hjartarson A. Comparison of clinical and videofluoroscopic evaluation of children with feeding and swallowing difficulties. Dev Med Child Neurol 2005;47:149-157.).

RESULTS

The study sample consisted of 29 patients: 10 patients with laryngomalacia and 19 patients with glossoptosis. The sensitivity of clinical evaluation did not exceed 50% in any of the evaluations, but specificity reached 100% in some cases, using thickened liquids. The prevalence of dysphagia was 100%, and the use of thickened liquids significantly reduced tracheal aspiration.

CONCLUSIONS

Dysphagia was highly prevalent in this sample. The sensitivity of clinical evaluation to detect laryngeal penetration and tracheal aspiration was low, as the majority of aspiration events were silent. The videofluoroscopic study is important in order to determine a safest method to feed the patient. Pediatr Pulmonol. 2017;52:41-47. © 2016 Wiley Periodicals, Inc.

Practice patterns in supraglottoplasty and perioperative care

OBJECTIVES

Supraglottoplasty is the first-line surgical treatment for severe laryngomalacia. The purpose of this study is to determine the current trends of practice patterns in managing children who require supraglottoplasty.

METHODS

A 25-question survey regarding supraglottoplasty techniques and perioperative management was sent by e-mail to 274 physician members of the Society for Ear, Nose and Throat Advances in Children (SENTAC).

RESULTS

101 surgeons responded and 72% of respondents were in academic practice (p < 0.0001). All four United States regions, Canada and the United Kingdom were represented. The most commonly reported age of patients undergoing supraglottoplasty was 1-3 months (62% of respondents). Indications include worsening airway symptoms (43%), failure to thrive (41%) and worsening feeding (10%). The majority of respondents (89%) treat these patients for reflux with 54% prescribing PPIs and 41% prescribing H2 blockers. Cold steel is the most popular surgical technique (73%) followed by laser (14%), microdebrider (10%) and coblator (3%) (p < 0.0001). Most respondents (92%) administer intraoperative steroids with the majority of them choosing dexamethasone (99%). Perioperative antibiotics are administered by 23% of respondents. Almost all respondents admit their patients for post-operative observation (99%) and 53% of these admit to PICU rather than step-down or floor status. The level of care is associated with the number of supraglottoplasties performed per year (p = 0.009) and with the geographic region (p = 0.02). Surgeons who perform fewer supraglottoplasties tend to admit to a higher level of care. Those in the South and Northeast regions tend to admit more to floor status. Only 13% routinely keep patients intubated post-operatively.

CONCLUSIONS

This provider survey study highlights some significant variations and trends in practice patterns of otolaryngologists who perform supraglottoplasty. The majority utilizes anti-reflux pharmacotherapy; however, there is no consensus in which type. The method for supraglottoplasty also varies with cold steel being the most popular, although no single method has been shown to be superior. There is variation in post-operative care with trends for keeping patients extubated and admitting them to an intensive care. With the importance of safe, effective, and also cost-conscious care, further studies are needed to understand the optimal management of those who undergo supraglottoplasty.

Treatment outcome of supraglottoplasty vs. wait-and-see policy in patients with laryngomalacia

In most cases, laryngomalacia presents as a mild disease, and the symptoms resolve after wait-and-see policy. Up to 20 % of patients present with severe laryngomalacia and may require surgery (i.e. supraglottoplasty); however, the indication for surgery is not firmly established yet. The goal of this study is to determine whether supraglottoplasty results in a better outcome than wait-and-see and to investigate how different comorbidities influence outcome. A retrospective study of pediatric cases of in a tertiary referral center was performed. Photo and video documentation was available and revised in all cases. Electronic and paper charts were reviewed for the following variables: gender, sex, gestational age, birth weight, symptoms, comorbidity, date of endoscopy, severity and type of laryngomalacia, treatment modality and technique and follow-up data and a total 89 patients were included. Supraglottoplasty was found to lead to significantly faster complete improvement of laryngomalacia than wait-and-see policy (5 weeks vs. 29, p = 0.026). Synchronous airway lesions (SALs) were present in 40.4 % of patients and were associated with prolonged symptoms of laryngomalacia (38.5 weeks vs. 14.5, p = 0.043). Supraglottoplasty is safe and effective in treatment of severe laryngomalacia. SALs and comorbidities are frequently found in patients with laryngomalacia and are responsible for longer onset of complaints.

[The size of the vocal folds in the children during the first years of life]

The objective of the present study was to determine the size of the vocal folds in the children during the first several years of life. The study included 137 children at the age from the birth up to 3 years who were referred to our clinic for the pre-planned surgical intervention with the use of endotracheal intubation. The length and the width of the vocal folds from the muscle tubercle to the anterior commissure in abduction were measured using a probe specially designed and adapted for this purpose. In all the cases, the endoscope was positioned at the same distance from the vocal folds. The fold length (ab) and width (cd) were expressed in millimeters. These parameters were measured in the following age groups of the patients: from the birth to 1 month 29 days (group 1), from 12 mo to 23 mo 29 d (group 2), from 24 mo to 35 mo 29 d (group 3), and above 36 months (group 4). The length and the width of the vocal folds varied from 2.6 mm to 7.8 mm and from 1.3 mm to 3.2 mm respectively. The length of the vocal folds increased at a rate of 1.025 mm per year showing marked variations within each age group, from the maximum value of 1.79 mm during the second year of life to the minimum of 0.48 mm during the fourth year. The authors conclude that these data may be of use for the improvement of the quality of the surgical treatment and subsequent rehabilitation of the respiratory and voice-generating functions of the larynx.

Laryngomalacia and swallowing function in children

OBJECTIVES/HYPOTHESIS

1) To determine the prevalence of dysphagia in children with laryngomalacia, 2) To ascertain whether severity of laryngomalacia influences the presence of swallowing dysfunction, and 3) To examine whether patients with medical comorbidities and laryngomalacia have a higher prevalence of swallowing dysfunction.

STUDY DESIGN

Retrospective cohort study.

METHODS

All patients seen in the aerodigestive center at our institution between January 2007 and December 2012 with the diagnosis of laryngomalacia were included. Swallowing function was assessed by symptoms, clinical swallowing evaluations (CSE) performed by speech pathologists, modified barium swallow (MBS) studies, and fiberoptic endoscopic evaluations of swallowing (FEES).

RESULTS

There were 324 patients with laryngomalacia identified (41.4% female, 58.6% male). Severity of laryngomalacia was categorized in 279 patients, with 62.7% mild, 28.7% moderate, and 8.6% severe. Gastroesophageal reflux disease (GERD) was diagnosed in 69.8% of patients. Other medical comorbidities included Down syndrome (3.1%), neurological impairment (6.5%), and congenital heart disease (0.9%). Symptoms of dysphagia or feeding difficulty were present in 163/324 (50.3%), and failure to thrive was present in 31/324 patients (9.6%). At least one abnormal swallowing assessment was present in 97/120 (80.8%) patients presenting with subjective dysphagia and 43/65 (66.2%) patients without subjective dysphagia. A total of 140/185 (75.7%) patients had at least one abnormal baseline swallowing assessment. There was no significant relationship between severity of laryngomalacia and presence of abnormal swallowing function based on symptoms, CSE, MBS, or FEES. However, patients with greater severity were more likely to have failure to thrive. There was not a significant association between the presence of swallowing dysfunction or disease severity and medical comorbidities such as Down syndrome, neurological impairment, or congenital heart disease. However, GERD was more likely to be present in patients with moderate and severe laryngomalacia than in patients with mild disease.

CONCLUSIONS

Swallowing dysfunction is common in children with laryngomalacia regardless of disease severity or other medical comorbidities. Swallowing studies are frequently abnormal in laryngomalacia patients presenting both with and without subjective symptoms of dysphagia. Dysphagia assessment should be considered as part of the evaluation of infants with laryngomalacia.

LEVEL OF EVIDENCE

4.

Supraglottoplasty in Infants

Objective:

While generally well tolerated for the treatment of severe laryngomalacia, bilateral supraglottoplasty has potential complications including supraglottic stenosis and aspiration. We report a more conservative staged supraglottoplasty in infants with severe laryngomalacia.

Methods:

A retrospective review was performed of our patients who underwent staged supraglottoplasty from June 2007 to June 2012. Fifteen infants were identified and scored based on stridor, retractions, oxygen saturation, and feeding quality. Outcomes were compared with those reported in the literature for conventional bilateral supraglottoplasty.

Results:

Seventy-three percent had significant improvement or resolution of stridor following the first stage of surgery and 100% in those undergoing a second stage. Twelve patients (80%) had mild to no retractions following one procedure and 100% had resolution after a second surgery. All 6 patients with recurrent preoperative desaturations had resolution after the first stage of surgery. Of the 11 infants who had preoperative moderate-severe feeding problems, 9 of them (82%) had resolution after one surgery and the remaining 2 had resolution after a second surgery. There were no complications in any of the patients.

Conclusions:

Staged supraglottoplasty appears to be an effective, low-risk method to treat severe laryngomalacia. A second procedure was only required in 40% of patients.

Surgical management of type I and II laryngeal cleft in the pediatric population

INTRODUCTION

Laryngeal clefts (LC) are congenital malformations of the upper aerodigestive tract that can cause dysphagia, aspiration, and subsequent pulmonary complications. This investigation assessed the outcomes of multidisciplinary evaluation and surgical management of type I and II LC (LC1-2) at a tertiary children's hospital.

MATERIALS AND METHODS

A retrospective chart review was used to identify patients who underwent repair of LC1-2 by a single surgeon.

RESULTS

Twenty-five patients who underwent surgical management for LC1-2 were identified. Twenty patients with LC-1 and 5 with LC-2 were included. Most common presentations were aspiration on modified barium swallow (MBS) (76%) and recurrent pulmonary infections (60%). Gastroesophageal reflux disease (GERD) was a concurrent co-morbidity in 68%. Of the 19 patients who presented with preoperative aspiration on MBS, 52.6% had evidence of improvement on their first MBS. This improved to 78.9% at the time of their most recent MBS (10 with resolution of aspiration, 5 with improved tolerance of consistencies). Two patients failed to improve from surgical repair and two had worsened aspiration on most recent MBS.

CONCLUSION

Endoscopic repair of laryngeal clefts is a well-tolerated procedure. Concurrent GERD and positive bronchoalveolar lavage (BAL) cultures are common and require management prior to definitive repair. Given the multidimensional nature of swallowing disorders and aspiration, a comprehensive team approach in the evaluation, management, and surveillance of these patients is a valuable complement to surgical repair since not all aspiration may resolve.

Transient swallowing dysfunction in typically developing children following supraglottoplasty for laryngomalacia

OBJECTIVE

To evaluate early postoperative swallowing function in otherwise typically-developing children following supraglottoplasty.

METHODS

Retrospective chart review case series.

RESULTS

Of 37 children identified as having undergone supraglottoplasty for severe laryngomalacia at our institution between January 2007 and October 2011, 24 were identified as otherwise typically developing with no indications/signs of swallowing problems pre-operatively and eligible for inclusion in this study. Twenty-two children underwent bilateral supraglottoplasty and 2 children underwent unilateral supraglottoplasty using the CO2 laser or the laryngeal skimmer microdebrider in combination with cold steel technique, based on the discretion of four Pediatric Otolaryngologists. Seventeen children were seen post-operatively for a clinical swallow evaluation. Six children were found to have swallowing dysfunction. Four of the six children showed variable symptoms, signs, or findings concerning for aspiration with oral feeding. Three of six underwent video fluoroscopic swallow study (VFSS). All 6 children responded to dietary modifications, positioning alterations, and anti-reflux medications. All showed improvement by their 4-week post-operative follow-up visit. The median age of the 24 patients at the time of surgery was 3 months, with a range from 2 weeks to 4 years. The median age of the patients found to have transient post-operative swallowing dysfunction was 1.5 months, with a range of 2 weeks to 4 months. There was no association between post-operative swallowing dysfunction and the surgical technique employed.

CONCLUSIONS

Supraglottoplasty in otherwise typically developing children carries a risk of transient swallowing dysfunction with a low risk of persistent dysfunction. Most patients can be assessed post-operatively via clinical swallow evaluation without requiring an instrumental swallow study.

Congenital laryngeal anomalies

Introduction

It is essential for clinicians to understand issues relevant to the airway management of infants and to be cognizant of the fact that infants with congenital laryngeal anomalies are at particular risk for an unstable airway.

Objectives

To familiarize clinicians with issues relevant to the airway management of infants and to present a succinct description of the diagnosis and management of an array of congenital laryngeal anomalies.

Methods

Revision article, in which the main aspects concerning airway management of infants will be analyzed.

Conclusions

It is critical for clinicians to understand issues relevant to the airway management of infants.

The effects of prematurity on incidence of aspiration following supraglottoplasty for laryngomalacia

OBJECTIVES

To determine if patients who were born premature have a higher incidence of aspiration following supraglottoplasty compared to patients born full term.

STUDY DESIGN

Retrospective study.

METHODS

Two thousand three hundred sixty (2360) patient charts from Riley Hospital for Children were reviewed retrospectively. Patients had already been treated for laryngomalacia with supraglottoplasty by Dr. Bruce Matt. Estimated weeks gestational age at birth was recorded for each patient. Prematurity was stratified as mild (32-36 weeks gestational age [WGA]), very (28-31 WGA), or extremely (<28 WGA). Patients were excluded from the study if they had suspected aspiration with chronic cough, pneumonia, chronic lung disease, or documented aspiration prior to supraglottoplasty.

RESULTS

As previously shown, 75 patients (3.2%) had aspiration following supraglottoplasty. Twenty of these patients were preterm infants at birth. The rate for aspiration following supraglottoplasty for former premature infants was statistically significant (5.9%, odds ratio = 2.3, P = .0032).

CONCLUSIONS

Children who were born premature have a higher rate of postoperative aspiration following supraglottoplasty; however, supraglottoplasty should still be considered as treatment for laryngomalacia as the rate is still relatively low (5.9%).

Supraglottoplasty in Premature Infants with Laryngomalacia

Purpose

Prematurity is thought to be to be an independent risk factor for supraglottoplasty (SGP) failure. The purpose of this study was to compare the outcomes of supraglottoplasty in premature infants with congenital laryngomalacia (LM) with that of term infants.

Study Design

Case series with chart review.

Setting

Tertiary-care pediatric institution.

Methods

Analysis was performed on 325 consecutive patients undergoing SGP between 2004 and 2012. Patients older than 12 months age or with syndrome, neurologic, or cardiac comorbidities were excluded. Resolution of airway symptoms after SGP was considered successful while revision SGP and tracheostomy were considered failures. The rates of secondary airway lesions (SAL), dysphagia, and gastrostomy tube (GT) placement were also compared.

Results

A total of 176 infants (136 term, 40 preterm) were identified. SGP was successful in 92.7% term and 90% preterm infants with no significant difference ( P = .5865). Incidence of revision SGP and tracheostomy was similar among the groups. The outcomes of SGP were the same in all groups stratified by age. Incidence of SAL was significantly higher in preterm (72.5%) compared to term infants (34.6%, P = .0002). Dysphagia rates in the follow-up were higher in preterm (32.5%) versus term infants (6.6%, P < .001). The rate of GT insertion was significantly greater ( P = .003) in preterm (27.5%) than term infants (6.6%). The preoperative dysphagia, persistent dysphagia, and GT in follow-up was significantly higher when gestation age <32 weeks (25%, P = .0168).

Conclusion

Supraglottoplasty outcomes in term and preterm infants were similar irrespective of gestation age. Higher rates of dysphagia in follow-up are seen when gestation age <32 weeks.

Laryngomalacia

Laryngomalacia is the most common cause of stridor in infants. Stridor results from upper airway obstruction caused by collapse of supraglottic tissue into the airway. Most cases of laryngomalacia are mild and self-resolve, but severe symptoms require investigation and intervention. There is a strong association with gastroesophageal reflux disease in patients with laryngomalacia, and thus medical treatment with antireflux medications may be indicated. Supraglottoplasty is the preferred surgical treatment of laryngomalacia, reserved only for severe cases. Proper identification of those patients who require medical and surgical intervention is key to providing treatment with successful outcomes.