Consensus on Triple Endoscopy Data Elements Preparatory to Development of an Aerodigestive Registry

Socioeconomic and Ethnic Disparities in Timing and Outcome of Interarytenoid Injection Augmentation

OBJECTIVES

To investigate the relationship between social determinants of health and timeliness of management, adherence to follow-up, and outcomes of treatment with interarytenoid injection augmentation (IAIA).

METHODS

Retrospective cohort study of all pediatric patients treated with IAIA at a large pediatric institution's multidisciplinary aerodigestive clinic between August 2022 and February 2024. Retrieved demographic factors, dates of referral, consultation, treatment, and follow-up, as well as objective measures of dysphagia and aspiration via videofluoroscopic swallow study (VFSS) reports, using dysphagia outcome and severity scale (DOSS) scores and the greatest unsafe thickness, or 'aspiration score'. These factors were analyzed for correlation with social determinants of health determined through the Area of Deprivation Index (ADI).

RESULTS

A total of 120 patients, median age 15 months were included. All underwent IAIA for the indication of persistent pharyngeal dysphagia. The median national ADI score was 45. Patients experienced average improvement in laryngeal penetration and aspiration from an aspiration score of slightly thick preoperatively to thin postoperatively, and improvement in dysphagia from mild-moderate to mild. No correlation was identified between ADI, race and ethnicity, or sex and measures of timeliness of treatment, loss to follow-up, receipt of feeding therapy, or outcome of treatment.

CONCLUSION

Addressing persistent dysphagia in pediatric patients with IAIA seems to be equivalently efficacious across a wide population, and outcome did not vary significantly depending on patients' race or socioeconomic contexts. This finding may be due in part to the utilization of a well-organized multidisciplinary center to treat these complex patients.

LEVEL OF EVIDENCE

4 Laryngoscope, 135:2164-2170, 2025.

Esophageal pathology and the aerodigestive triple endoscopy for pediatric recurrent croup

Recurrent croup (RC) is characterized by recurrent episodes of stridor, barking cough, and hoarseness. While viral infections are the primary cause in croup, RC is thought to be caused by non-infectious etiologies such as structural airway abnormalities, allergic disorders, airway hyperresponsiveness and gastroesophageal reflux (GERD). Recent studies have suggested a potential link between esophageal diseases, particularly GERD/reflux esophagitis and eosinophilic esophagitis (EoE), and RC. This retrospective study aims to explore the association between esophageal disorders and RC through a multidisciplinary approach. A total of 68 patients with RC were identified in our aerodigestive center, 47 of whom underwent dual or triple endoscopy. Of these, 17 patients (36 %) were found to have esophageal disease, including EoE (15 %) and reflux esophagitis (19 %). Notably, food allergies were significantly more prevalent in the EoE group, and all patients with EoE had reported GI symptoms previously. While airway abnormalities were common across all groups, there were no significant differences between patients with and without esophageal disease. The study highlights the prevalence of esophageal diseases in patients with RC, particularly EoE, and a multidisciplinary aerodigestive evaluation may be beneficial for diagnosing concomitant esophageal conditions. Further studies are needed to determine the causal relationship between esophageal disorders and RC.

Multidisciplinary aerodigestive team meetings for the management of complex airway patients

OBJECTIVE

To examine the clinical profiles and management of patients discussed at our tertiary paediatric hospital's multidisciplinary aerodigestive team (ADT) meetings.

METHOD

Retrospective chart review of all patients discussed at the Perth Children's Hospital ADT meetings between December 2018 and July 2022. Patient demographics, clinical characteristics and meeting outcomes, including procedures, investigations and follow-up were reviewed.

RESULTS

A total of 580 ADT meeting consults were recorded for 304 patients, with 116 patients requiring multiple consultations. The median age at time of consult was 2.74 years and 51.0 % of patients were male. The commonest aerodigestive tract disorders included tracheomalacia (20.7 %), laryngomalacia (20.7 %), laryngotracheal stenosis (13.2 %), gastro-oesophageal reflux (9.4 %) and tracheo-oesophageal fistula (9.4 %). A secondary diagnosis was seen in 45.5 % of patients, most commonly Trisomy 21 (10.2 %), Robin Sequence (4.9 %) and Cerebral Palsy (3.0 %). Children with secondary diagnoses (P < 0.01), tracheostomy dependence (P < 0.01), upper airway disorders (P < 0.01) and oesophageal disorders (P < 0.01) were more likely to require multiple ADT consults. Further investigations were ordered after 25.9 % of consults, most commonly polysomnography (14.9 %) and video fluoroscopic swallowing studies (6.1 %). A total of 742 procedures were performed to diagnose and/or treat aerodigestive disease. The commonest diagnostic procedures were microlaryngoscopy and bronchoscopy (46.9 %), upper gastrointestinal endoscopy (7.8 %) and sleep nasendoscopy (6.7 %). The commonest interventional surgical procedures were adenoidectomy (12.4 %), balloon dilation of laryngotracheal stenosis (9.4 %), steroid injection to laryngeal scar or granulation tissue (8.4 %) and supraglottoplasty (6.7 %).

CONCLUSION

The aerodigestive program utilises a multidisciplinary approach to manage a medically complex cohort of patients. This study presents a large sample of patients from an Otolaryngology-led aerodigestive program in Australia and is intended to guide development of aerodigestive programs across the world in various clinical contexts.

Efficacy and Complications of Interarytenoid Injection for Dysphagia in Infants 1-Year-Old and Under

OBJECTIVE

The objective of this study was to assess the efficacy and complication rates of interarytenoid injection augmentation (IAIA) for the treatment of dysphagia in patients 1 year of age and under and to determine if concurrent feeding therapy (FT) affects outcome.

STUDY DESIGN

Retrospective case series.

SETTING

Tertiary pediatric hospital.

METHODS

Retrospective review of patients 13 months of age and younger with dysphagia treated by IAIA over a 4-year period. The efficacy of IAIA was determined by comparing perioperative videofluoroscopic swallow studies (VFSS) and Dysphagia Outcome and Severity Scale (DOSS) scores. Complication rates and utilization of concomitant FT were determined by evaluating postoperative admission and follow-up records.

RESULTS

Sixty-five patients met inclusion criteria (median age 8 months, interquartile range [IQR]: 7-11). Sixty-seven percent of patients improved on postoperative VFSS scores (median improvement in aspiration of 2 thickness levels, IQR 0-3, P < .0001), and 56% improved in DOSS scores (median increase of 1, IQR: 0-1.5, P < .0001). Ninety-two percent of patients were discharged home on the day of surgery. The 30-day relevant readmission rate was 5%. No patients had intraoperative complications or severe complications at follow-up. No statistical difference in aspiration or DOSS was noted in the concomitant FT cohort due to a lack of sample size.

CONCLUSION

This study demonstrates that IAIA in children under 13 months old shows comparable rates of success and complications to older patients reported in the literature. No patients had long-term complications and most were discharged home on the day of surgery. More studies are needed to determine the effect of concomitant FT on IAIA.

Toward Better Semantic Interoperability of Data Element Repositories in Medicine: Analysis Study

BACKGROUND

Data element repositories facilitate high-quality medical data sharing by standardizing data and enhancing semantic interoperability. However, the application of repositories is confined to specific projects and institutions.

OBJECTIVE

This study aims to explore potential issues and promote broader application of data element repositories within the medical field by evaluating and analyzing typical repositories.

METHODS

Following the inclusion of 5 data element repositories through a literature review, a novel analysis framework consisting of 7 dimensions and 36 secondary indicators was constructed and used for evaluation and analysis.

RESULTS

The study's results delineate the unique characteristics of different repositories and uncover specific issues in their construction. These issues include the absence of data reuse protocols and insufficient information regarding the application scenarios and efficacy of data elements. The repositories fully comply with only 45% (9/20) of the subprinciples for Findable and Reusable in the FAIR principle, while achieving a 90% (19/20 subprinciples) compliance rate for Accessible and 67% (10/15 subprinciples) for Interoperable.

CONCLUSIONS

The recommendations proposed in this study address the issues to improve the construction and application of repositories, offering valuable insights to data managers, computer experts, and other pertinent stakeholders.

Consensus on intake questionnaire data elements in the development of an aerodigestive registry

OBJECTIVE

To define the essential elements of the intake questionnaire that will be a part of a larger multicenter registry for aerodigestive patients.

METHODS

A modified Delphi method was utilized to obtain consensus on the data elements that should warrant inclusion in the final research database. Patient questionnaires from the eight participating institutions were reviewed and individual elements were aggregated into 14 categories.

RESULTS

A total of 198 initial elements were voted on for inclusion. The categories included demographics, respiratory symptoms, gastrointestinal symptoms, ear nose and throat symptoms, feeding, birth history, medical history, surgical history, family history, social history, medications prior to evaluation, devices used prior to evaluation, prior diagnostic evaluations, and prior evaluation by aerodigestive team members. 83 of the 198 elements met consensus for inclusion in the final registry for an inclusion rate of 41.9 %. Three separate rounds of ranking were required to obtain consensus.

CONCLUSION

The aerodigestive registry is an important initiative that will help foster research and help guide future management. The intake questionnaire of the registry is a critical component of this project, and the consensus obtained during this study should help create a streamlined and efficient registry that will help all aerodigestive patients on a national level.

Application of the Delphi method to the development of common data elements for social drivers of health: A systematic scoping review

Collaborative data science requires standardized, harmonized, interoperable, and ethically sourced data. Developing an agreed-upon set of elements requires capturing different perspectives on the importance and feasibility of the data elements through a consensus development approach. This study reports on the systematic scoping review of literature that examined the inclusion of diverse stakeholder groups and sources of social drivers of health variables in consensus-based common data element (CDE) sets. This systematic scoping review included sources from PubMed, Embase, CINAHL, WoS MEDLINE, and PsycINFO databases. Extracted data included the stakeholder groups engaged in the Delphi process, sources of CDE sets, and inclusion of social drivers data across 11 individual and 6 social domains. Of the 384 studies matching the search string, 22 were included in the final review. All studies involved experts with healthcare expertise directly relevant to the developed CDE set, and only six (27%) studies engaged health consumers. Literature reviews and expert input were the most frequent sources of CDE sets. Seven studies (32%) did not report the inclusion of any demographic variables in the CDE sets, and each demographic SDoH domain was included in at least one study with age and sex assigned at birth included in all studies, and social driver domains included only in four studies (18%). The Delphi technique engages diverse expert groups around the development of SDoH data elements. Future studies can benefit by involving health consumers as experts.

Anesthesia for laryngotracheal reconstruction in children: A narrative review

Laryngotracheal stenosis, congenital or acquired, is a common cause of pediatric airway obstruction. Acquired subglottic stenosis frequently results from prolonged neonatal intubation. The clinical presentation of subglottic stenosis is variable, ranging from biphasic stridor and frequent upper respiratory infections to acute airway compromise. Optimal patient care requires clinical coordination within a multidisciplinary subspecialty team. Medical management includes optimizing respiratory status, gastroesophageal reflux, speech, feeding, nutrition therapies, and providing psychosocial support. If surgical intervention is required, the otolaryngologist, anesthesiologist, and perioperative team must collaborate closely to ensure successful operative outcomes. This narrative review of laryngotracheal stenosis will discuss the pathophysiology, clinical evaluation, medical management, and surgical interventions, and focus on the perioperative anesthetic considerations for children undergoing laryngotracheal reconstruction.

Gastrointestinal factors associated with risk of bronchiectasis in children

OBJECTIVE

To evaluate gastrointestinal (GI) risk factors for bronchiectasis in children. We hypothesized that upper GI tract dysmotility would be associated with increased risk of bronchiectasis.

STUDY DESIGN

Subjects in this retrospective cohort study included those evaluated for persistent pulmonary symptoms in the Aerodigestive Center at Boston Children's Hospital who underwent chest computed tomography (CT) between 2002 and 2019. To determine gastrointestinal predictors of bronchiectasis, baseline characteristics, comorbidities, enteral tube status, medications received, gastroesophageal reflux burden, adequacy of swallow function, esophageal dysmotility, gastric dysmotility, and neutrophil count on bronchoalveolar lavage (BAL) were compared between patients with and without bronchiectasis. Proportions were compared with Fisher's exact test and binary logistic regression with stepwise selection was used for multivariate analysis. ROC analyses were utilized to compare BAL neutrophils and bronchiectasis.

RESULTS

Of 192 subjects, 24% were found to have evidence of bronchiectasis on chest CT at age 7.9 ± 0.5 years. Enteral tubes (OR 5.77, 95% CI 2.25-14.83, p < 0.001) and increased BAL neutrophil count (OR 5.79, 95% CI 1.87-17.94, p = 0.002) were associated with increased risk while neurologic comorbidities were associated with decreased risk (OR 0.24, 95% CI 0.09-0.66, p = 0.006). Gastroesophageal reflux was not found to be a significant risk factor. Neutrophil counts >10% had 72% sensitivity and 60% specificity for identifying bronchiectasis.

CONCLUSIONS

Enteral tubes were associated with significantly increased risk of bronchiectasis but gastroesophageal reflux was not. Providers should consider obtaining chest CT to evaluate for bronchiectasis in children found to have unexplained elevated BAL neutrophil count.

Pathogenic bacteria in bronchoalveolar lavage cultures and pediatric laryngotracheal reconstruction outcomes

OBJECTIVE

The primary objective was to determine if treating pathogenic bacteria in bronchoalveolar lavage (BAL) cultures improves outcomes after pediatric double stage laryngotracheal reconstruction (dsLTR).

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary children's hospital.

METHODS

All children (<18 years) obtaining flexible bronchoscopy with BAL cultures before dsLTR between 2016 and 2022 were included. Cultures identified abnormal bacterial growth or normal respiratory flora. Thirty-day postoperative surgical site or lung infections were captured and tracheostomy decannulation rates were obtained for children with at least 12 months of follow-up.

RESULTS

Twenty-seven children obtained presurgical BAL cultures before dsLTR. Median age at reconstruction was 2.9 years (interquartile range: 2.3-3.5) and 89% (24/27) had high grade subglottic stenosis. Positive cultures were obtained in 56% of children (N = 15) with Pseudomonas aeruginosa (40%, 6/15) and methicillin-resistant Staphylococcus aureus (33%, 5/15) the most frequent organisms. All children with positive cultures were treated based on culture and sensitivity data. Postoperative infections developed in 22% (6/27) of children with equal distribution of surgical site and respiratory infections among children with pathogenic bacteria and normal respiratory flora. At 12 months after surgery, the decannulation rate was no different between those treated and not treated for a presurgical positive BAL culture (47% vs. 58%, p = 0.70).

CONCLUSION

Pathogenic bacteria are common in BAL cultures from tracheostomy-dependent children before dsLTR. Treatment keeps respiratory infections and decannulation rates similar to children with negative cultures, suggesting continued benefit of flexible bronchoscopy and BAL in preparation for these surgeries.

Airway Impedance: A Novel Diagnostic Tool to Predict Extraesophageal Airway Inflammation

OBJECTIVE

To validate a novel biomarker, airway impedance for extraesophageal disease.

STUDY DESIGN

We prospectively recruited patients with respiratory symptoms undergoing combined endoscopy and direct laryngoscopy for the evaluation of symptoms. The direct laryngoscopy was performed and videotaped for blinded scoring by 3 otolaryngologists and an impedance catheter was placed onto the posterior larynx to obtain measurements. Following this, an endoscopy was performed and impedance measurements and biopsies were taken at 3 esophageal heights. Impedance values were compared within and between patients.

RESULTS

Eighty-eight patients were recruited, of which 73 had complete airway and endoscopic exams. There was no significant correlation between airway impedance values and mean reflux finding scores (r² = 0.45, P = .07). There was no significant positive correlation between airway impedance and esophageal impedance values (r² = 0.097-0.138, P > .2). Patients taking proton pump inhibitors had significantly lower mean airway impedance values (706 ± 450 Ω) than patients not taking them (1069 ± 809 Ω, P = .06). Patients who had evidence of aspiration on video fluoroscopic swallow studies had lower airway impedance (871 ± 615 Ω) than patients without aspiration (1247 ± 360 Ω, P = .008). Inhaled steroids did not impact airway impedance levels (P = .7).

CONCLUSIONS

Airway impedance may be an important diagnostic tool to diagnose gastroesophageal reflux or aspiration, eliminating the subjectivity of airway appearance alone.

Making the case for multidisciplinary pediatric aerodigestive programs

Multidisciplinary pediatric aerodigestive centers have been proposed to address the needs of children with complex multi-system problems affecting the respiratory and upper gastrointestinal tracts. The setup of a multidisciplinary service allows for the complex coordination needed between different subspecialties. This allows for rapid communication and family-centered decision making and agreement on further diagnostic and/or therapeutic next steps such as offering triple endoscopy when indicated. Triple endoscopy entails performing rigid upper airway assessment, flexible bronchoscopy and upper gastrointestinal endoscopy and has been linked to reduced time to diagnosis/treatment, reduced costs and anesthesia exposure. This review summarizes the available literature on the structure and benefits of multidisciplinary pediatric aerodigestive services.