Outcomes and predictors of surgical management in type 1 laryngeal cleft swallowing dysfunction

Outcomes of Injection Laryngoplasty for Deep Interarytenoid Groove

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

Interarytenoid injection outcomes in pediatric feeding disorders

Objectives

Type 1 laryngeal clefts (LC1) and deep interarytenoid grooves contribute to pediatric feeding disorders. Management of these defects remains heterogeneous among surgeons and interarytenoid injection augmentation (IIA) is not always offered as a treatment option. This study evaluated IIA outcomes among a pediatric patient cohort comprised mostly of those with deep interarytenoid grooves.

Methods

A single-institution retrospective chart review featured children under the age of 5 years presenting for aspiration, dysphagia, or choking. Over the period of 7 years (January 2014-October 2021), 39 met inclusion criteria and had sufficient follow-up data. Descriptive statistics and subgroup analyses were performed.

Results

Of the 39 included patients, 76.92% had clinical improvement post-injection, with the mean time to follow-up being 47 days. Within the deep interarytenoid groove group, improvement rates were 82.76%. Bronchoscopy findings revealed 29 (74.36%) patients with a DIG, 3 (7.69%) with LC1, 3 (7.69%) with no anatomic abnormality, and 4 (10.26%) with vocal cord paralysis. There were no adverse events. There were no associations with the outcomes based on subgroup analysis and logistic regression.

Conclusions

IIA is an effective and safe treatment for pediatric feeding disorders. No covariates were associated with symptom improvement. Within the deep interarytenoid groove diagnosis subgroup, IIA effectively improved symptoms. Further investigations are needed to explore predictors of success with IIA in this population.

Level of Evidence

VI.

Spectrum of swallowing abnormalities in children with Type I laryngeal cleft

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Combined laryngeal cleft injection laryngoplasty and salivary botulinum toxin for saliva aspiration

Objectives

Children with type I laryngeal clefts and sialorrhea can have posterior drooling, aspiration of oral secretions, and respiratory complications. Laryngeal cleft injection laryngoplasty (LCIL) and salivary botulinum injections (Sal‐Bot) have been used separately for short‐term treatment of type I laryngeal clefts and sialorrhea. Our goal was to evaluate combined LCIL and Sal‐Bot and create recommendations for further treatment based on response to initial treatment.

Methods

Retrospective chart review of nine patients who underwent direct laryngoscopy and bronchoscopy with combined LCIL and Sal‐Bot from 2012 to 2019. Charts were reviewed for patient characteristics, response to treatment, and pre and post‐op hospitalizations. Subsequent procedures were performed depending on efficacy of initial treatments.

Results

Nine patients were identified. All had pre‐existing neurologic conditions, gastrostomy tubes, and a history of coughing and choking on secretions. Only one patient was able to feed orally (purees). 1 U/kg of botulinum toxin per gland was injected into each parotid and submandibular gland. The average units of botulinum toxin injected was 67 U. The mean laryngeal cleft injection volume was 0.35 cc. Subsequent treatment was based on timing of symptomatic improvement and individual patient factors. Five patients had respiratory‐related hospitalizations in year preceding the procedures (median 1.5, range 1–10). Three (60%) had a reduction in respiratory‐related hospitalization 1 year post procedure (median 1, range 1–3). One patient died during the follow up period due to continued chronic respiratory failure.

Conclusions

This is the first study of combined laryngeal cleft injection laryngoplasty and botulinum toxin injections for patients with posterior laryngeal penetration and aspiration of oropharyngeal secretions. We highlight strategies for choosing subsequent procedures based on response to initial treatment.

Level of Evidence

4.

Postoperative respiratory adverse events in children after endoscopic laryngeal cleft repair

PURPOSE

Due to the serious nature of respiratory adverse events, understanding their incidence can help in decisions regarding safe postoperative disposition. There have been no studies, however, evaluating the risk of postoperative respiratory adverse events (PRAEs) in children undergoing endoscopic laryngeal cleft (LC) repair, which is the primary objective of this study.

METHODS

We conducted a retrospective chart review of all patients who underwent LC repair at a large tertiary children's hospital from 2015 to 2020. PRAEs were defined as having at least one of the following: remained intubated, required reintubation, required positive pressure ventilation, required high flow O₂ nasal cannula, or required more than one dose of racemic epinephrine. Univariate analyses compared demographic, preoperative characteristics, and intraoperative characteristics between those with and without a PRAE.

RESULTS

Overall, 8/26 (31%) patients had a PRAE and there were no differences between patients who did and did not have a PRAE and most comorbidities. Younger age (p = 0.03), being male (p = 0.07), and being admitted preoperatively (p = 0.07) were potentially associated with PRAEs. Need for intraoperative intubation for any reason or duration was associated with increased incidence of PRAEs (p = 0.02).

CONCLUSION

The overall 31% incidence of postoperative respiratory adverse events reaffirms the appropriateness of PICU disposition for a large proportion of children undergoing endoscopic LC repair. Further studies with increased sample sizes are needed to tease apart patient or procedure-specific factors that significantly increase the risk of respiratory adverse events to have more definitive evidence regarding safe postoperative disposition.

Laryngeal cleft: A literature review

INTRODUCTION

Laryngeal cleft is a congenital condition in which an opening in the posterior laryngotracheal wall allows food and liquid to pass from the esophageal lumen to the airway and causes aspiration. The severity of a laryngeal cleft is measured using the Benjamin-Inglis system, and can be managed conservatively or with a variety of surgical options With increased awareness, higher suspicion among primary physicians, advanced technology and improved intensive neonatal care services, more babies with laryngeal clefts survive in the modern era. Therefore, the focus has shifted from infant survival to treatment of laryngeal clefts and the challenging, complex medical conditions they create.

OBJECTIVE

To understand current laryngeal cleft management and post-operative outcomes.

METHODS

Literature review of laryngeal cleft studies from 2010 to 2021.

RESULTS

A total of 1033 patients were included. Based on 415 cases for whom sufficient classification data were available, the predominate symptom for patients with type I, III, and IV clefts is swallowing dysfunction, while the predominant symptoms for patients with type II clefts are stridor and aspiration. A wide variety of comorbidities involving several major organs has been reported with laryngeal clefts, which tend to impact clinical outcomes negatively. Approximately 19% of type I clefts have been treated conservatively successfully, but the majority was treated surgically. Most studies that used injection laryngoplasty for type I clefts reported highly successful repairs without complications or delays in additional procedures. Ninety-eight percent all type II clefts were treated with endoscopic repair; 87% of patients with type III clefts received endoscopic repair; and 66% of patients with type IV clefts underwent open surgery. Approximately 62% of resolved cases were reported within 12 months, while 50.87% of failed cases were reported within 6 weeks.

CONCLUSIONS

There are multiple treatment approaches, each of which may be applicable depending on factors such as laryngeal cleft type, severity of presentation, and comorbidities. Conservative approaches appear to be most useful for type I clefts or in patients with mild symptoms, while surgical management can be considered for any type of laryngeal cleft. The benefit of injection laryngoplasty, endoscopic repair and open surgery can also vary, but injection laryngoplasty and endoscopic repair are used most commonly. Open surgery should be to be considered if patients present with severe cleft types or if it is unsafe to perform other surgical techniques. Familiarity with this literature review should help clinicians understand clinical characteristics, direct medical management, and guide successful resolution of laryngeal clefts.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Management of Type 1 Laryngeal Clefts: A Systematic Review and Meta-analysis

OBJECTIVE

Endoscopic surgical management or injection laryngoplasty of type 1 laryngeal clefts in pediatric patients is used in those who do not respond to conservative treatment. This study compares conservative treatment, endoscopic surgical repair, and injection laryngoplasty for the management of type 1 laryngeal clefts.

DATA SOURCES

PubMed, Web of Science, and Embase.

REVIEW METHODS

This systematic review included studies of patients with type 1 laryngeal clefts who were managed with conservative treatment, injection laryngoplasty, or endoscopic repair, and all studies reported postintervention outcomes. Two independent investigators assessed study eligibility, rated the quality, and extracted data for analysis. A random effects model was used for meta-analysis of pooled data.

RESULTS

Of the 1209 studies identified, 27 met inclusion criteria. There were 543 patients with type 1 laryngeal clefts represented in the studies, with outcomes reported for 537. Conservative therapy had a 52% (95% CI, 37%-66%; I² = 63%) success rate at improving symptoms, while endoscopic repair had a significantly higher percentage resolution of symptoms (70%; 95% CI, 59%-79%; I² = 62%, P < .001) as compared with conservative treatment (51%; 95% CI, 36%-65%; I² = 62%) or injection laryngoplasty (36%; 95% CI, 20%-57%; I² = 70%). The quality scores of the studies ranged from 7 to 12 out of 16.

CONCLUSION

Our systematic review demonstrated significant improvement and resolution of symptoms for patients with type 1 laryngeal clefts treated with endoscopic repair as compared with other modalities. More prospective and controlled studies comparing treatment strategies with validated instruments to measure outcomes are necessary to determine their efficacy in the management of type 1 laryngeal clefts.

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

Objectives

To describe indications for injection augmentation (IA), endoscopic repair (ER) and conservative methods for the management of type 1 laryngeal cleft (LC1) and propose a management algorithm. We also aimed to compare success of IA and ER and determine independent predictors of treatment failure.

Methods

Retrospective study of patients diagnosed with LC1 at a Pediatric Otolaryngology referral centre between 2004 and 2016. All had pre-operative instrumental swallowing evaluation (VFSS/FEES), and were managed with a combination of conservative measures, IA and/or ER. We collected demographics, symptoms, comorbidities, VFSS/FEES results, and operative details. The primary outcome was symptom resolution by parental report. The secondary outcome was predictors of treatment failure.

Results

88 patients were included in the analysis, with mean age 26 ± 25 months. Most presented with choking events (68%) or recurrent pneumonias (48%). In total, there were 55 IA performed and 45 ER. Of the patients who received IA, 19 required subsequent ER. 95% had symptom improvement, 67% had complete resolution. IA had a 56% long-term success rate, whereas that for ER was 85%. Tube feeding at initial evaluation was an independent predictor of treatment failure (HR 11.33 [1.51–84.97], p = 0.018).

Conclusions

LC1 can be effectively managed with a combination of IA and ER with favorable results. Failure to respond to IA does not preclude ER, and both have their role in management. Patients who are tube fed have a higher probability of treatment failure. We propose a management algorithm that includes reasoning for conservative approaches, and reduces exposure to general anesthesia.

Postoperative respiratory complications and disposition in patients with type 1 laryngeal clefts undergoing injection or repair - A single institution experience

OBJECTIVE

Identify incidence and factors associated with respiratory complications after type 1 cleft repair.

METHODS

Retrospective chart review of patients who underwent cleft repair over a 5-year period performed by a single surgeon. Primary endpoint was respiratory complications (oxygen desaturation <90%). Fisher's exact test was used to identify differences between repair types (endoscopic carbon dioxide laser-assisted repair and injection laryngoplasty). Logistic regression was used to identify predictors of respiratory events.

RESULTS

Fifty-five patients were included. Thirty-four (62%) patients underwent endoscopic carbon dioxide laser-assisted repair and 21 (38%) underwent injection laryngoplasty. Average hospital stay for each group was 1.6 days (SD = 3.1) and 0.6 days (SD = 0.9), respectively. Desaturations occurred in three patients (9%) in the laser-assisted repair group and one patient (4%) in the injection group. All occurred within 3 h after surgery and resolved with supplemental oxygen, oral airway placement, and/or mask ventilation. Two affected patients had comorbid diagnosis of asthma (one had poor medication compliance), and one had a history of developmental delay and hypotonia. In the injection group, desaturations occurred in one patient with a history of tracheal stenosis and double aortic arch. No correlation existed between repair type and desaturation (p = 0.57). No variables were significant predictors of events.

CONCLUSIONS

In this cohort, respiratory events after type 1 laryngeal cleft repair occurred early in the postoperative period, in children with cardiac and pulmonary comorbidities. This suggests postoperative admission may only be necessary for a select group of patients undergoing type 1 cleft repair. However, further research is needed to determine criteria for same-day discharge.

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

INTRODUCTION

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

METHOD

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

RESULTS

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

CONCLUSION

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

Long-term swallowing outcomes following type 1 laryngeal cleft injection

INTRODUCTION

Interarytenoid injection augmentation (IIA) during initial diagnostic endoscopy for aspiration and dysphagia has been described as both a diagnostic and therapeutic technique in the evaluation of type 1 laryngeal cleft (LC-1). IIA is additionally hypothesized to be a temporizing measure that facilitates improvement of swallowing function and potentially obviates the need for future formal endoscopic suture repair of LC-1. However, long-term (>6 month) outcomes of IIA for LC-1 remain largely unknown. The objective of this study was to evaluate the effect of IIA on long-term swallowing outcomes and need for formal endoscopic suture repair in patients with LC-1.

METHODS

This is a retrospective cohort study of patients age ≤24 months with pharyngeal phase dysphagia on preoperative videofluoroscopic swallow study (VFSS) who underwent IIA for LC-1 during diagnostic laryngoscopy and bronchoscopy at a single tertiary care academic subspecialty hospital from June 2017 to May 2018. Included patients underwent VFSS within 30 days of IIA and had documented SLP follow up at 6 months or more post-procedure. Exclusion criteria included prior cleft repair, gastrostomy tube dependence, additional procedures at the time of IIA, or lack of documented follow up. A total of 34 patients underwent LC-1 during study period with 24 included in final analyses. The primary outcome measure was improvement in safely swallowed consistency at 6 months or greater following injection. Secondary outcomes included need for formal suture LC-1 repair following IIA and comparison of 30-day and long-term swallowing function.

RESULTS

Median [range] age at injection was 15.3 [10.3-19.1] months and 50% were female (n = 12). Improvement was noted in 12 (50%) patients within 30 days of IIA, with 11 of 12 demonstrating sustained improvement at long-term follow up (10.3 [9.3-14.0] months). Among all patients, 15 of 24 (63%) demonstrated improvement compared to preoperative baseline. Six of 24 (25%) required formal suture repair of LC-1.

CONCLUSIONS

IIA is a safe procedure that may result in both immediate and long-term improvement in dysphagia in select patients with LC-1. Additional studies are required to determine impact of IIA on pulmonary complications and hospital utilization and as well as patient- and caregiver-related outcome measures.

Injection bronchoplasty with carboxymethlycellulose with cystoscopy needle for neonatal persistent bronchopleural fistulae

OBJECTIVE

We describe the novel use of injectable carboxymethylcellulose to close a persistent bronchopleural fistula (BPF) in a neonate who underwent an ex utero intrapartum treatment (EXIT) after aborted fetoscopy.

METHODS

In this case, a patient with laryngeal atresia underwent fetoscopy that was halted after concern for instruments within the mediastinum, and thus ultimately required an EXIT to establish an airway. Bilateral pneumothoraces and eventually multiple BPF were identified that continued to persist despite multiple attempts at removal of chest tubes over a four-week period. We look at the role of endoscopy and a substance often used in the larynx to help close a persistent BPF.

RESULTS

At initial bronchoscopy, no BPF was identified, but at subsequent evaluation due to persistent pneumothorax, we used increased positive end expiratory pressure to help reveal the fistula. Given the bronchial location of the fistula, traditional laryngeal instruments could not be used, requiring the use of urologic cystoscopy needles to assist in accessing these challenging locations. At postoperative day 2 from the injection, the chest tube was removed and did not require replacement.

CONCLUSION

There are many methods to help treat BPF. The endoscopic injection of carboxymethylcellulose adds a technique to the pediatric otolaryngologist's armamentarium.

Reliability and Construct Validity of the Penetration-Aspiration Scale for Quantifying Pediatric Outcomes after Interarytenoid Augmentation

OBJECTIVE

To assess the reliability and construct validity of the Penetration-Aspiration Scale in children.

STUDY DESIGN

This was a retrospective cohort study of pre- and postoperative video modified barium swallow studies from children who underwent interarytenoid injection augmentation for unexplained persistent pharyngeal dysphagia. Two pediatric speech and language pathologists reviewed each study twice in a blinded and randomized fashion.

SETTING

Tertiary academic pediatric hospital.

SUBJECTS AND METHODS

Thirty children were identified with adequate pre- and postoperative modified barium swallow studies within 4 weeks of intervention. Children were separated into clinical outcome groups based on ability to advance to thinner diet consistencies postoperatively. Construct validity was assessed with a mixed linear model to test the hypothesis that only the clinically improved group would receive better Penetration-Aspiration Scale scores after surgery. Reliability was assessed by calculating chance-corrected agreement between raters (interrater) and raters' repeat evaluations (intrarater).

RESULTS

Inter- and intrarater reliabilities (Cohen's κ) were both excellent. Results of the mixed model revealed a significant interaction between outcome group and pre- and postoperative time interval. As hypothesized, this involved a significant improvement in Penetration-Aspiration Scale score only in the improved group.

CONCLUSIONS

These findings suggest that the Penetration-Aspiration Scale is a reliable and valid measure of clinical response to interarytenoid injection augmentation in children.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Outcomes and swallowing evaluations after injection laryngoplasty for type I laryngeal cleft: Does age matter?

OBJECTIVES

To improve the recognition of differences in presentation amongst patients with type 1 laryngeal clefts of various ages and better understand the age dependent outcomes of injection laryngoplasty. A second aim was to analyze the discrepancies between swallow assessment modalities in various age groups with type I laryngeal clefts undergoing injection laryngoplasty.

METHODS

A retrospective review of electronic medical records of patients who underwent injection laryngoplasty from 2009 through 2015 at a tertiary care children's hospital. Data extracted included: Demographics, histories and physical exam findings, diagnostic studies, and medical and surgical treatments.

RESULTS

Most (72/102, 70.6%) patients were male with a median gestational age at birth of 37 weeks (range 24-41 weeks). Formula thickening and GERD medications were used in 94/102 (92.2%) and 97/102 (95.1%) patients, respectively. Comorbid GERD, laryngomalacia, tracheomalacia, and subglottic stenosis were present in 98/102 (96.1%), 40/102 (39.2%), 9/102 (8.8%), and 14/102 (13.7%) patients, respectively. There was no significant difference in demographics, comorbidities or medical therapy between age groups. Symptoms at presentation differed between age groups with stridor (χ²(1) = 11.6, p = 0.002) and cyanosis (χ²(1) = 8.13, p = 0.012) being more common in the 0-3-month group compared to the 12-36 month group. Symptom resolution and the odds of undergoing additional surgery (second injection or suture repair) over time, however, did not differ. There was a significant reduction in aspiration with thins during FEES (McNemar χ²(1) = 10.7, p = 0.002) and aspiration with nectar during MBS (McNemar χ²(1) = 5.26, p = 0.035) post-injection. After injection, there was significant agreement in aspiration with thins between FEES and MBS (kappa = 0.308 ± SE 0.170, p = 0.035). However, finding aspiration with thins was more common during MBS than during FEES (McNemar χ²(1) = 7.00, p = 0.016). There were no differences in swallow evaluation findings between the age groups.

CONCLUSIONS

Symptoms of type I laryngeal clefts may differ by age. However, there was no impact of age on the safety and efficacy of surgical intervention.

Mucocele formation following laryngeal cleft injection

A 12-month-old male underwent injection laryngoplasty for dysphagia associated with a deep interarytenoid notch. He subsequently developed a large postcricoid mucocele requiring revision surgery and marsupialization of the cyst just 2 weeks following the initial surgery. Laryngoscope, 129:1696-1698, 2019.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

Dysphagia in healthy children: Characteristics and management of a consecutive cohort at a tertiary centre

OBJECTIVE

Whereas the literature is replete with reports on complex children with dysphagia (DP), the parameters characterizing non-neurologically impaired (NNI) children have been underreported, leaving a substantial knowledge gap. We set to characterize a consecutive cohort of NNI children, their management, and outcomes.

METHODS

We undertook a retrospective case series. Children (<18 years old) attending a tertiary multidisciplinary swallowing clinic were eligible. Patients with neuro-developmental, neuromuscular, or syndromic abnormalities were excluded. Primary outcomes included demographics, co-morbidities, presentations, McGill score, swallowing and airway abnormalities (and their predictors). Secondary outcomes were interventions and management response.

RESULTS

From 171 consecutive patients (37-month period), 128 were included (69 males, median age 6.6 months (0.5-124.2)). Significant clinical presentations included recurrent pneumonias (20), cyanotic spells (14) and life-threatening events (10). Swallowing assessments revealed laryngeal penetration (67), aspiration (25). Other investigations included overnight oximetry (77), airway (70), and gastrointestinal endoscopy (24); revealing laryngomalacia (29), laryngeal mobility disorder (8), and subglottic stenosis (8). Non-surgical interventions involved oral diet modifications (85) and enteral nutrition (15). Surgical interventions included supraglottoplasties (18), endoscopic laryngeal cleft repair (14), and injection (19). 119 patients received intervention and at last follow-up (median 5.2 months (0.3-88.8)) 94 had improved. Of those treated 116 were on an unmodified oral diet, and 24 on a modified diet. ALTE and snoring predicted airway abnormalities, recurrent pneumonia predicted swallowing abnormalities, and age and airway lesions predicted the McGill score.

CONCLUSION

a significant proportion of NNI children with DP harbor airway and swallowing abnormalities warranting endoscopic and instrumental assessment.