Timeline to dysphagia resolution after endoscopic intervention of an interarytenoid defect based on Video Fluoroscopic Swallow Study dysphagia severity

INTRODUCTION

We previously reported that endoscopic repair of a Type 1 Laryngeal Cleft (LC1) or Deep Interarytenoid Groove (DIG) improves swallowing function postoperatively. However, caregivers often ask about the timeline to resolution of the need for thickening. This study re-examines this cohort to answer this important caregiver-centered question.

METHODS

We reassessed a 3-year retrospective, single-center dataset of children with dysphagia found to have a LC-1 or DIG on endoscopic exam. The primary outcome was rate of complete resolution of dysphagia at 2, 6, and 12 months after endoscopic intervention. A sub-group analysis was made based on severity of dysphagia prior to intervention and by type of endoscopic repair.

RESULTS

Thirty-nine patients with mean age 1.35 years that had a LC-1 or DIG met criteria for inclusion. Rate of complete dysphagia resolution increased over time. Those with mild dysphagia (flow-reducing nipple and/or IDDSI consistency 1 or 2) had brisker resolution than those with moderate dysphagia (IDDSI consistency 3 or 4) at 2 months (67% vs 5%, p < 0.01) and at 6 months (80% vs 18%, p < 0.01) after endoscopic repair. There was no difference in dysphagia resolution between patients grouped by type of endoscopic repair.

CONCLUSION

Addressing an interarytenoid defect in patients will not result in immediate, complete dysphagia resolution in most patients. However, patients that only require a flow-reducing nipple and/or thickening to an IDDSI consistency 1 or 2 have brisker resolution of the need for thickening than those that require an IDSSI consistency 3 or 4 prior to intervention. These results inform pre-operative discussions of the timeline to resolution based upon severity of dysphagia and help manage caregiver expectations.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Human salivary immunoglobulin and antigen-specific antibody activity after tonsillectomy

The importance of the lymphoid tissue collectively known as Waldeyer's ring, which includes the palatine, lingual and nasopharyngeal tonsils, in the induction and contribution of specific antibody responses in human saliva is not clear. The purpose of this study was to determine whether salivary immunoglobulin A (IgA) levels differ in quantity and quality between subjects who have had a tonsillectomy and age, sex and race-matched controls. Parotid saliva, whole saliva, and blood serum samples were collected from 25 volunteer children who had undergone tonsillectomy (T-) within 6-14 months of sampling and from 25 age, sex and race-matched controls. The levels of total IgA (and subclasses) in saliva, and of antigen-specific salivary IgA and serum IgA and IgG antibodies to 4-9 relevant antigens were analyzed by ELISA. No significant difference was observed in the mean total IgA and IgA subclass levels in parotid and whole saliva, although the mean levels for children with a T- were slightly lower. Children with a T- had significantly higher parotid salivary IgA and IgA1 specific/total activity than controls. The total and specific whole saliva IgA and the specific serum IgA or IgG activities were not significantly different from controls. These results indicate an association between the removal of tonsils and increased levels of specific IgA activity in parotid saliva within the first year after a T-.

Chloroma of the masseteric muscle

Chloroma (leukemic infiltrate or granulocytic sarcoma) is a localized extramedullary mass of immature granulocytic cells. They are uncommon tumors that usually occur in patients with leukemia, mostly of the myeloid type. Involvement in the head and neck region is rare. Granulocytic sarcomas of the face, maxilla, paranasal sinuses, temporal bone, and pharynx have all been documented in the past. We present the first reported case of a granulocytic sarcoma involving the masseteric muscle in an 8-month-old white male diagnosed with acute myeloid leukemia (AML). The lesion resolved with chemotherapy but the patient subsequently died. This case reaffirms the importance of including chloroma in the differential diagnosis of lesions in patients with AML and the prognostic value they hold.

Opsomyoclonus and neuroblastoma

Three cases of neuroblastoma with opsomyoclonus are reported, reconfirming favorable prognostic significance of the association. In one case, computed tomography of the abdomen was the only confirmatory diagnostic study. Two of the cases also were unusual in that the patients had a concomitantly inherited genetic disorder not known to be associated with childhood cancer.