Furlow double-opposing z-plasty

First described in 1978 by Furlow for the repair of a cleft soft palate, the double-opposing z-plasty, also known as the Furlow palatoplasty, is an excellent procedure for repairing a submucous cleft. It is also useful in patients with touch closure who simply need lengthening of the soft palate and as an option for patients with anomalous carotid vasculature where pharyngeal flaps and sphincter pharyngoplasty are precarious. The primary aims of this chapter are to provide the clinician with indications for when to consider utilizing the Furlow palatoplasty and to give a stepwise description of how to perform the procedure.

Comparison of Hybrid Laryngotracheal Reconstruction to Traditional Single- and Double-Stage Laryngotracheal Reconstruction

Objectives

(1) To describe outcomes from and modifications to the hybrid laryngotracheal reconstruction (LTR) technique and (2) to compare this technique to traditional single- and double-stage LTR (ssLTR/dsLTR).

Study Design

Chart review with case series.

Setting

Tertiary care otolaryngology specialty hospital.

Subjects

All patients under 18 years of age who underwent LTR by a single surgeon from July 1, 2009, to December 31, 2013.

Methods

Charts were assessed for age, gender, etiology of stenosis, type of reconstruction, comorbidities, length of stay, complications, and tracheostomy status. Analysis was performed using Kruskal-Wallis and Wilcoxon rank sum analysis.

Results

Forty-four patients were identified, with 13 hybrid LTRs, 27 ssLTRs, and 4 dsLTRs. Of the hybrid LTRs, an overall decannulation rate of 76.9% was noted, comparable to those for dsLTR. The hybrid LTR technique offered a significantly shorter period of narcotic use when compared to ssLTR (median 15 vs 21 days, P < .01). No patients in the hybrid LTR group developed supraglottic granulation tissue. There was no statistically significant difference in median length of stay for ssLTRs, dsLTRs, and hybrid LTRs ( P = .38).

Conclusion

The hybrid LTR technique is well tolerated and useful in patients of all ages. Narcotics can be weaned more quickly due to the presence of a secure airway at all times via the existing tracheostomy. Use of a long stent prevents formation of granulation tissue that may be seen with a suprastomal stent. This technique should be considered in patients with high-grade stenosis with a preexisting tracheostomy.

Systemwide change of sedation wean protocol following pediatric laryngotracheal reconstruction

IMPORTANCE

Pediatric laryngotracheal reconstruction (LTR) remains the standard surgical technique for expanding a stenotic airway and necessitates a multidisciplinary team. Sedation wean following LTR is a critical component of perioperative care. We identified variation and communications deficiencies with our sedation wean practice and describe our experience implementing a standardized sedation wean protocol.

OBJECTIVE

To standardize and decrease length of sedation wean in pediatric patients undergoing LTR.

DESIGN, SETTING, AND PARTICIPANTS

Using Institute for Healthcare Improvement (IHI) methodology, we implemented systemwide change at a tertiary care center with the goal of improving care based on best practice guidelines. We created a standardized electronic sedation wean communication document and retrospectively examined our experience in 29 consecutive patients who underwent LTR before (n = 16, prewean group) and after (n = 13, postwean group) wean document implementation.

INTERVENTIONS

Implementation of a standardized sedation protocol.

MAIN OUTCOMES AND MEASURES

Presence of sedation wean document in the electronic medical record, length of sedation wean, and need for continued wean after discharge.

RESULTS

The sedation wean document was used in 92.3% patients in the postwean group. With the new process, the mean (SD) length of sedation wean was reduced from 16.19 (11.56) days in the prewean group to 8.92 (3.37) days in the postwean group (P = .045). Fewer patients in the postwean group required continued wean after discharge (81.3% vs 33.3%; P = .02).

CONCLUSIONS AND RELEVANCE

We implemented a systemwide process change with the goal of improving care based on best practice guidelines, which significantly decreased the time required for sedation wean following LTR. Our methodological approach may have implications for other heterogeneous patient populations requiring a sedation wean.

Use of imaging to evaluate course of the carotid artery in surgery for velopharyngeal insufficiency

OBJECTIVE

This study aimed to describe syndromes where preoperative imaging may be essential in determining the course of the carotid arteries before velopharyngeal insufficiency (VPI) surgery and therefore affect surgical planning.

METHODS

Records of children who underwent surgery for VPI between May 1, 2012, and October 30, 2013, at a tertiary care pediatric otolaryngology center were reviewed. Data collected included age at operation, preoperative and postoperative nasometry values, presence of underlying genetic disorders, and imaging findings.

RESULTS

Twenty-five patients underwent 33 surgeries for VPI, with 1 posterior pharyngeal wall augmentation, 6 Furlow palatoplasties, 11 sphincter pharyngoplasties, and 15 pharyngeal flaps. Medialized carotid vasculature was identified in 5 of 25 patients (20%). Seven syndromic patients were identified, with 3 patients having 22q11.2 deletion syndrome. All patients (100%) with 22q11.2 deletion syndrome had medialized carotid arteries. Of the 4 additional syndromic children, 2 (50%) had medial internal carotid arteries, with 1 patient diagnosed with neurofibromatosis 1 and another with Prader-Willi syndrome. Both patients underwent Furlow palatoplasty.

CONCLUSION

Whereas 22q11.2 deletion syndrome is recognized as an entity where a medial carotid is often present, other syndromic children may also demonstrate vascular variability. Although a larger study is needed to confirm an increased prevalence in these patients, clinicians may need a higher degree of suspicion while performing the physical examination. If examination findings are suggestive or the disease process may lend itself to this abnormality, vascular imaging can be considered as part of presurgical planning to help guide surgical technique and prevent complications.

A Novel Technique for Endoscopic Type I Laryngeal Cleft Repair

Objectives:

(1) Describe a novel technique for repair of type I laryngeal clefts. (2) Review the current literature on various techniques for repair of type I laryngeal clefts.

Methods:

A retrospective review of patients under 18 years with a type I laryngeal cleft who underwent endoscopic laryngeal cleft repair (LCR) by a single surgeon at a tertiary care otolaryngology specialty hospital using a successful novel technique from July 1, 2013, to February 14, 2014, was conducted. This technique uses electrocautery to demucosalize the cleft on a setting of 6, followed by repair of the cleft with 2 endoscopically placed sutures. Charts were assessed for age at surgery, comorbidities, diet, length of stay, complications, and outcomes.

Results:

Eleven patients were identified, with an average age of 28 months (range, 9-68 months). Eight of 11 (73%) of patients were restricted to nectar thick-diet preoperatively, 2 out of 11 (19%) to honey thick-diet, and 1 out of 11 (9%) to half-strength honey thick-diet. Postoperative swallow results were available for 7 patients. Five of 7 patients demonstrated clinical or radiographic evidence of resolution of aspiration. One had improvement of aspiration but persistent penetration, and another had continued aspiration and is being evaluated for a neurologic disorder.

Conclusions:

Although type I laryngeal clefts have traditionally been endoscopically addressed using either a cold technique or a laser to demucosalize the cleft, our technique offers an advantage over cold knife by providing improved hemostasis and broader demucosalization. In addition, when compared with the laser technique, it offers similar broad demucosalization without deeper thermal damage.

Evaluation of True Vocal Fold Growth as a Function of Age

Objectives:

Evaluate change in true vocal fold length as function of age.

Methods:

Prospective study at tertiary aerodigestive center between 2011 and 2013. A total of 205 patients (ages 1 month to 20 years), of which 87 (42.4%) were female and 118 (57.6%) male, were included. Lengths of total vocal fold (TVFL), membranous vocal fold (MVFL), and cartilaginous vocal fold (CVFL) were measured during direct laryngoscopy. Membranous-to-cartilaginous ratios (M/C) were calculated.

Results:

Mean MVFL under age 1 year for females was 4.4 ± 1.3 mm and for males 4.9 ± 1.8 mm. At age 17 years, mean MVFL was 12.3 ± 2.1 mm for females and 14.0 ± 1.4 mm for males. Mean TVFL, MVFL, and CVFL increased 0.7 mm, 0.5 mm, and 0.2 mm per year in linear fashion, respectively (linear regression, P < .0001). M/C ratio did not significantly change with age ( P = .78). Mean TVFL, MVFL, and CVFL showed trend of being longer in males than females, but these did not reach statistical significance ( P = .27; .11; .75, respectively).

Conclusions:

This is the largest longitudinal pediatric study specifically examining vocal fold length as function of age. Each length of true vocal fold appears to linearly increase for both females and males. M/C ratio remained relatively constant unlike previously reported data, possibly due to in vivo versus cadaveric measurements. These findings suggest critical periods of development in females and males are not explainable by changes in vocal fold length alone, and other factors such as vocal fold layers (linear density) need further exploration.

New Concepts in Pediatric Otolaryngology: A Video Forum

Program Description:

In this state-of-the-art miniseminar, 7 experts will share video-based examples of new ideas in pediatric otolaryngology. New knowledge, techniques, and outcomes for emerging concepts will be discussed while ample opportunity for audience questions and answers will be provided. Steven L. Goudy: endoscopic-assisted pharyngeal surgery. Christopher J. Hartnick: optical coherence tomography in the operating room; differentiating cysts from nodules. Sanjay R. Parikh: drug-induced sleep endoscopy: technique and findings. Soham Roy: mechanical models of operating room airway fires. Michael J. Rutter: slide tracheoplasty for difficult tracheoesophageal fistula. David R. White: a new understanding of congenital nasal stenosis. Carlton J. Zdanski: transoral robotic surgery: pearls and pitfalls.

Educational Objectives:

(1) Characterize novel ideas for pediatric airway surgery techniques and concepts. (2) Prevent airway fires during surgery. (3) Practice novel techniques for understanding pediatric sleep apnea evaluation.

Comparison of Hybrid Laryngotracheal Reconstruction to Traditional Single and Double-Stage Laryngotracheal Reconstruction

Objectives:

(1) Describe outcomes from and modifications to the hybrid, also known as the one-and-a-half stage, laryngotracheal reconstruction (LTR) technique. (2) Compare this technique to traditional single and double-stage LTR (ssLTR/dsLTR).

Methods:

Retrospective review of patients under 18 years of age who underwent LTR by a single surgeon at a tertiary care otolaryngology specialty hospital from July 1, 2009, to December 31, 2013, was performed. Charts were assessed for age, sex, etiology of stenosis, type of reconstruction, comorbidities, length of stay, complications, and tracheostomy status.

Results:

Forty-four patients were identified, with 13 one-and-a-half stage LTRs, 27 ssLTRs, and 4 dsLTRs. Of the one-and-a-half stage LTRs, an operation-specific decannulation rate of 77% was noted, comparable with those for ssLTR and dsLTR. The one-and-a-half stage LTR technique offered a significantly shorter period of narcotic use when compared with ssLTR (16 vs 23 days, P < .01). Average length of stay for ssLTRs and hybrid LTRs was identical at 16 days; difference in length of stay between hybrid and dsLTRs was not statistically significant (16 vs 12.5 days, P = .16).

Conclusions:

The hybrid LTR technique is well-tolerated and useful in patients of all ages. Narcotics are able to be weaned more quickly because of the presence of a secure airway at all times via the existing tracheostomy. Use of a long stent prevents formation of granulation tissue that may be seen with a suprastomal stent. This technique should be considered in patients with high-grade stenosis with a pre-existing tracheostomy.

Evaluation of True Vocal Fold Growth as a Function of Age

Objective

To evaluate change in true vocal fold length as a function of age.

Study Design

Prospective study.

Setting

Tertiary aerodigestive center.

Subjects and Methods

In total, 205 patients (aged 1 month to 20 years), of whom 87 (42.4%) were female and 118 (57.6%) male, were included. Lengths of the total vocal fold (TVFL), membranous vocal fold (MVFL), and cartilaginous vocal fold (CVFL) were measured during direct laryngoscopy. Membranous-to-cartilaginous (M/C) ratios were calculated.

Results

For patients younger than 1 year, mean (SD) MVFL was 4.4 (1.3) mm for females and 4.9 (1.8) mm for males. At age 17 years, mean (SD) MVFL was 12.3 (2.1) mm for females and 14.0 (1.4) mm for males. Mean TVFL, MVFL, and CVFL increased an average of 0.7 mm, 0.5 mm, and 0.2 mm per year in linear fashion, respectively (linear regression, P < .0001). The M/C ratio did not significantly change with age ( P = .33). Mean TVFL, MVFL, and CVFL showed no statistical difference between males and females ( P = .27, .11, and .75, respectively).

Conclusion

This is the largest longitudinal pediatric study specifically examining vocal fold length as a function of age. Each length of the true vocal fold appeared to linearly increase for both females and males. The M/C ratio remained relatively constant, unlike previously reported data, possibly due to in vivo vs cadaveric measurements. These findings suggest that critical periods of development in females and males are not explainable by changes in vocal fold length alone, and other factors such as vocal fold layers need further exploration.

Operation airway: the first sustainable, multidisciplinary, pediatric airway surgical mission

OBJECTIVE

This study aimed to describe the development and implementation of the first sustainable, multidisciplinary, pediatric airway surgical mission in an underserved country.

METHODS

This prospective, qualitative study was conducted for the first 4 Operation Airway missions in Quito, Ecuador. The major goals of the missions were to assist children with aerodigestive abnormalities, create a sustainable program where the local team could independently provide for their own patient population, develop an educational curriculum and training program for the local team, and cultivate a collaborative approach to provide successful multidisciplinary care.

RESULTS

Twenty patients ages 4 months to 21 years were included. Twenty-three bronchoscopies, 5 salivary procedures, 2 tracheostomies, 1 T-tube placement, 1 tracheocutaneous fistula closure, 2 open granuloma excisions, and 6 laryngotracheal reconstructions (LTRs) were performed. All LTR patients were decannulated. A new type of LTR (1.5 stage) was developed to meet special mission circumstances. Two videofluoroscopic swallow studies and 40 bedside swallow evaluations were performed. One local pediatric otolaryngologist, 1 pediatric surgeon, 3 anesthesiologists, 7 intensivists, 16 nurses, and 2 speech-language pathologists have received training. More than 25 hours of lectures were given, and a website was created collaboratively for educational and informational dissemination (http://www.masseyeandear.org/specialties/pediatrics/pediatric-ent/airway/OperationAirway/).

CONCLUSION

We demonstrated the successful creation of the first mission stemming from a teaching institution with the goal of developing a sustainable, autonomous surgical airway program.

The utility of histopathology in identifying structural differences among layers of the lamina propria

OBJECTIVE

The purpose of this study is to assess the modality of laryngeal histopathology in identifying 1, 2, or 3 layers in the lamina propria.

METHODS

Blinded analysis was performed, with a set of histophathologic slides where the magnification and localized regions shown were all standardized. Two senior pathologists with experience reviewing laryngologic histophathology were asked to assess whether the vocal fold lamina propria they evaluated contained 1, 2, or 3 layers. Their ability to accurately assess this was calculated.

RESULTS

The first pathologist correctly identified 13 of 25 (52%) specimens. The second identified 19 of 25 (76%) specimens after receiving gold referents before the test. No significant difference was seen between the pathologists' interpretations (McNemar test; p = 0.0833).

CONCLUSION

Our results show the difficulty of using histopathology to distinguish layers in the lamina propria even when the reviewers are senior pathologists. These findings imply that more objective modalities for such analyses may be beneficial.

Pediatric Laryngology: Innovations and Updates

Program Description:

Pediatric laryngology has experienced tremendous growth with increased focus on voice issues. This miniseminar incorporates viewpoints of several clinicians and will focus on clinically relevant matters for general and specialty otolaryngologists, including diagnosis, common pathologies, and operative and non-operative approaches and techniques. Pathology includes benign vocal lesions, vocal fold paralysis, recurrent respiratory papillomatosis (RRP), laryngeal webs, and subglottic stenosis. Non-operative innovations will be discussed, including voice therapy, laryngeal electromyography, botulinum toxin, and fillers. Operative innovations include laser, techniques for vocal fold paralysis, and augmentations to standard open techniques. Differing practical approaches will be discussed in a panel format with presentations of challenging cases.

Educational Objectives:

1) Illustrate the diagnostic approach of pediatric laryngology and give practical advice towards successful techniques. 2) Describe various diagnostic challenges in pediatric laryngological diseases and illustrate approaches towards proper diagnosis and treatment. 3) Elucidate newer innovative techniques in pediatric laryngology through case discussion and panel discussion.

Prevalence of eosinophilic esophagitis in children with refractory aerodigestive symptoms

IMPORTANCE

Eosinophilic esophagitis (EoE) is an increasingly important diagnosis for children; it has a remarkable impact on their quality of life and can present with aerodigestive symptoms commonly evaluated by otolaryngologists.

OBJECTIVES

To evaluate the prevalence of EoE in children presenting to a pediatric aerodigestive clinic, to describe their presentation, and to review the role of subsequent food allergy evaluation and treatment.

DESIGN

Review of a prospective database.

SETTING

Tertiary pediatric multispecialty aerodigestive center.

PATIENTS

Children with aerodigestive symptoms refractory to medical treatment who underwent direct laryngoscopy with rigid or flexible bronchoscopy and esophagoscopy with or without pH probe study.

MAIN OUTCOMES AND MEASURES

Diagnosis of EoE.

RESULTS

Between 2003 and 2012, 376 of 1540 children seen in the center (mean [range] age, 4.54 [0-18.6] years; male to female ratio, 1.72:1) remained symptomatic despite medical therapy and thus underwent triple endoscopic evaluation. Of the 376 children, 14 (3.7%) were eventually diagnosed as having EoE, as defined by 15 or more eosinophils per high-power field on esophageal biopsy and either a negative pH study result or nonresponse to a trial of high-dose proton pump inhibitors. The subpopulation with EoE presented with airway symptoms and diagnoses, most commonly cough (n = 6; 42.9%). Inflammatory subglottic stenosis due to EoE was identified in 1 patient. Of the 14 children with EoE, 6 presented with gastrointestinal symptomatology, most commonly choking or gagging. Subsequent treatment including food allergy challenge and elimination diet resulted in a clinical improvement in half of the cases identified.

CONCLUSIONS AND RELEVANCE

This represents the largest multispecialty clinic epidemiologic study evaluating the prevalence of EoE in children presenting not strictly with gastrointestinal symptoms but rather with aerodigestive symptoms that are frequently evaluated by pediatric otolaryngologists. Although the prevalence is low, EoE should be considered for children with appropriate symptoms in whom other medical therapies fail.

Clinical Pearls in Pediatric Otolaryngology: A Video Forum

Program Description:

This video-based forum will provide audience members with state of the art concepts in pediatric otolaryngology. The speakers consist of: Carlton Zdanski: Transoral Robotic Surgery in Children: Indications and Results; Christopher Hartnick: Bevacizumab (Avastin) injection for pediatric RRP; Craig Derkay: Modifications of the Seldinger technique to secure the difficult pediatric airway; David White: Endoscopic division of the sternocleidomastoid muscle for treatment of torticollis; Ken Kazahaya: Endoscopic assisted otologic surgery; Michael Rutter: Tracheotomy tube fenestration; Sanjay Parikh: Diagnosis of sleep induced laryngomalacia; Soham Roy: Radiofrequency ablation of pediatric oral cavity lesions; Steven Goudy: Video-assisted pharyngeal surgery.

Educational Objectives:

1) Consider contemporary airway management ideas for tracheotomy tubes, recurrent papillomatosis, and laryngomalacia. 2) Describe novel endoscopic laryngopharyngeal techniques with robotics, radiofrequency, and video-assistance. 3) Implement novel endoscopic otologic and neck techniques.

Use of adjuvant intralesional bevacizumab for aggressive respiratory papillomatosis in children

IMPORTANCE

Juvenile recurrent respiratory papillomatosis (RRP) can be an aggressive disease process necessitating frequent trips to the operating room with multiple anesthetics for tumor debulking and airway preservation. Adjuvant therapy, such as that which is reported in this article, may help reduce the number of operative procedures affected children need each year and therefore may also affect their overall quality of life (QOL).

OBJECTIVE

To describe our experience with intralesional bevacizumab (Avastin) treatment for children with severe RRP by comparing median number of surgical procedures per year, median duration of time between procedures, Derkay staging, and voice QOL before and after bevacizumab treatment.

DESIGN

Prospective, consecutive case series.

SETTING

Tertiary care aerodigestive center.

PARTICIPANTS

Ten children, aged 18 months to 18 years, with severe RRP necessitating more than 4 operative interventions in 1 year whose parents (or legal guardians) consented to intralesional bevacizumab treatment.

INTERVENTIONS

Intralesional bevacizumab administered at concentration of 2.5 mg/mL for 3 consecutive injections (with 532-nm pulsed KTP [potassium titanyl phosphate] laser when necessary) at intervals of 2 to 3 weeks.

MAIN OUTCOME MEASURES

Time between surgical procedures, number of procedures per year, Derkay staging, total Pediatric Voice-Related Quality of Life (PVRQOL) score, Emotional PVRQOL score, and Physical PVRQOL score defined by comparing the year leading up to first of 3 bevacizumab injections with the year following the third bevacizumab injection.

RESULTS

The median duration of time between surgical procedures increased by 5.9 weeks after bevacizumab (P = .002). The median number of procedures per year decreased by 4 (P = .002). Derkay staging decreased by 6 (P = .03). The median total PVRQOL score increased by 25.5 (P = .02), the median Emotional PVRQOL score increased by 11.3 (P = .047), and the median Physical PVRQOL score increased by 14.3 (P = .047).

CONCLUSIONS AND RELEVANCE

Intralesional bevacizumab treatment may increase duration of time between surgical procedures and decrease number of procedures per year, while improving voice QOL.

Novel Method for Laryngotracheal Reconstruction: Combining Single- and Double-Stage Techniques

Objectives:

Traditional open techniques for laryngotracheal reconstruction are either single- or double-stage procedures. Some patients may benefit from the presence of a long, single-tube stent, such as an endotracheal tube, but their predicted need for a 2-stage procedure and a persistent tracheostomy is high. We describe a novel technique for airway reconstruction that combines the methods of both single- and double-stage procedures.

Methods:

We present a retrospective review of 4 patients. All patients underwent laryngotracheal reconstruction by a single surgeon. After the operation, the airway was stented with nasotracheal intubation. A small stent, fashioned from an endotracheal tube, was placed in the tracheostoma to keep it patent. The patients subsequently underwent extubation and replacement of the tracheostomy tube.

Results:

The study included 1 patient with grade 4 subglottic stenosis, 2 patients with grade 3 subglottic stenosis, and 1 patient with a posterior glottic scar. All were tracheostomy tube-dependent. Serial bronchoscopy was used to follow the patients for a minimum of 9 months after the operation. All 4 patients have since met the criteria for decannulation.

Conclusions:

This hybrid reconstruction merges the advantages of both the single- and double-stage procedures. It adds versatility to the surgical toolbox for airway reconstruction.

Modified superior pharyngeal flap for the treatment of velopharyngeal insufficiency in children

OBJECTIVE

To describe a modified rolled superior pharyngeal flap for treatment of velopharyngeal insufficiency (VPI) in children.

METHODS

Prospective case series at a tertiary care multidisciplinary aerodigestive center. Four children, aged 5-12 years, with VPI refractory to speech therapy resulting after cleft palate (bilateral, submucous, or soft palate only) repair, failed traditional superior pharyngeal flap, fine motor incoordination, or adenoidectomy were studied. All 4 children underwent surgery with a modified superior pharyngeal flap, where aspects of the most commonly employed pharyngeal flap designs were combined to achieve the benefits of each technique and to allow for mucosal covering on either side of the flap, improved control of the lateral port size due to the horizontal-to-horizontal inset technique, and the ability to avoid a vertical or horizontal split in a previously repaired cleft palate.

RESULTS

All 4 patients demonstrated resolution of their VPI as measured by subjective and/or objective criteria. Every patient required additional speech therapy postoperatively.

CONCLUSIONS

Our modified superior pharyngeal flap technique may be a good option in patients with small velopharyngeal gaps undergoing revision velopharyngeal surgery. A larger, longitudinal study would better address the overall outcomes of this technique.

Endoscopic CO2 laser laryngofissure in pediatric laryngotracheal reconstruction

Anterior laryngofissure is often needed to provide excellent visualization of the posterior cricoid lamina during pediatric laryngotracheal reconstruction. Focus has shifted from survival and decannulation outcomes to postoperative voice outcomes as surgical techniques continue to improve. Surgeons must perform the laryngofissure extremely precisely to avoid damage to the true vocal folds and ensure proper reapproximation of the anterior commissure. Endoscopic CO2 laser laryngofissure represents a novel technique to divide the anterior commissure and facilitate its accurate reapproximation.

Chiari type I malformation: presenting as chronic cough in older children

To highlight an unusual cause of chronic cough, we present two cases of chronic cough in older children referred to a pediatric otolaryngology outpatient clinic with persistent symptoms despite extensive previous workup and treatment. Cranial neuropathy was identified in each case. As a result, magnetic resonance imaging was performed revealing Chiari type I malformation. In each case, surgical decompression provided symptom improvement. Chronic cough is a rare presenting symptom in children with Chiari type I malformation. We emphasize the significance of awareness for unusual cases of cough to aid in the correct identification and treatment in children.