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.

Alterations in nasal physiology after laryngectomy: the nasal cycle

Several changes in nasal physiology have been reported following laryngectomy. This paper reviews these changes and investigates the cycle of alternating distribution of nasal airflow in 20 adults. Information about the cyclic activity was obtained from the areas of condensation formed by nasal expiration on the surface of a Gertner-Podoshin plate. Consecutive measurements of these areas were made at 15-minute intervals during a 6-8 hour period. Five control subjects demonstrated a nasal cyclic activity which was absent in five patients 1-3 years post-laryngectomy. Two patients with preoperative cycles showed none three weeks after laryngectomy. Three patients with a temporary surgical diversion of supraglottic airflow showed cessation of the cycle, which resumed after restoration of the natural airway; one of these patients had undergone hemilaryngectomy with section of both superior laryngeal nerves. Five patients showed no alteration after operation involving no diversion of supraglottic airflow (tonsillectomy). These results demonstrate cessation of the cycle following chronic absence of supraglottic airflow, temporary, cessation during acute absence, and independence of the cycle from superior laryngeal innervation.

The nasal cycle after laryngectomy

The cycle of alternating distribution of nasal airflow was investigated in 15 adults. Information about cyclic activity was obtained from the areas of condensation formed by nasal expiration on the surface of a Gertner-Podoshin plate. Consecutive measurements of these areas were made at 15 minute intervals during a 6-8 h period. Five control subjects demonstrated a nasal cyclic activity which was absent in 5 patients 1-3 years post laryngectomy. Two patients with preoperative cycles showed none 3 weeks after laryngectomy. Three patients with temporary surgical diversion of supraglottic airflow showed cessation of the cycle, which resumed after restoration of the natural airway; one of these patients had undergone hemilaryngectomy with section of both superior laryngeal nerves. These results demonstrate cessation of the cycle following chronic absence of supraglottic airflow, temporary cessation during acute absence, and independence of the cycle from superior laryngeal innervation.

Hypocomplementemia in Feline Lymphosarcoma

The feline leukemia virus (FeLV) is a contagiously spread oncornavirus that causes malignant transformation of lymphoid cells. Feline cells transformed by FeLV produce a new cell surface antigen, the Feline Oncornavirus Associated Cell Membrane Antigen (FOCMA), which is a tumor-specific cellular antigen specified by, but not part of, the virion (Hardy, in press). An indirect immunofluorescent antibody test for FeLV antigens in leukocytes of peripheral blood indicates that approximately 90% of cats with lymphosarcoma (LSA) are infected with FeLV. In response to infection the cat may produce FeLV neutralizing and/or FOCMA antibodies.

In the present study functional levels of total complement (TCH50), C4, C2, and Factor B were determined in cat sera. Protein levels of C1q were estimated by radial immunodiffusion using monospecific antiserum against cat C1q. A total of 60 animals were studied, 32 of which were normal and FeLV negative.

Complement and Feline Leukemia

Our interest in complement and leukemia has emerged from studies by Kassel et al. (J. Exp. Med., 138:925, 1973) and Hardy et al. (unpublished results) that infusion of normal plasma in mice, cats, and dogs causes massive dstruction of leukemic cells. Evidence in the mouse indicates that the anti-leukemic factor is a component of the complement system, C5. We have therefore begun to assay C and C component levels in cat serum. With functionally pure C1 and C2 and intermediate cells (EAC1, EAC4, EAC1,4) prepared from cat serum, the measurement of C1, C4 and C2 can be accomplished when the source of terminal C components, C3 to C9 is guinea pig serum in EDTA. With cat serum in EDTA, lysis does not occur. The blocking effect appears to be due to a potent inhibitor present in cat serum. This inhibitor is anti-complementary to guinea pig and human serum.