Neurostimulation for Pediatric Obstructive Sleep Apnea

Up to 80% of children with Down syndrome (DS) are affected by obstructive sleep apnea (OSA), and only 16% to 30% will have resolution of their OSA with adenotonsillectomy. Hypoglossal nerve stimulation is a well-established therapy for adults with OSA and was recently approved by the Food and Drug Administration for use in children with DS and residual OSA. There is robust experience with this therapy in adults that has led to well-established care pathways. However, given the challenges inherent to caring for a complex pediatric population, these pathways are not directly transferrable to children with DS.

Pediatric Down Syndrome Upper Airway Stimulation: Patient Selection and Post-Implantation Optimization

OBJECTIVE

The Food and Drug Administration recently approved upper airway stimulation (UAS) for children with Down Syndrome and persistent obstructive sleep apnea who meet certain inclusion and exclusion criteria. Although there is a robust experience with this therapy in the adult population, established protocols used in adults are not directly transferrable to a complex pediatric population. This review aims to combine the protocols from several institutions for patient selection and postimplantation optimization, including a protocol for Drug-Induced Sleep Endoscopy in children with Down Syndrome, preactivation threshold measurements, device titration, and follow-up sleep studies.

STUDY DESIGN

Expert panel development of best Practice algorithm.

SETTING

Multi-institutional investigator review.

METHODS

An expert panel was assembled of pediatric otolaryngologists with extensive experience in hypoglossal nerve stimulation in children with Down Syndrome. Thirty statements were created during an initial drafting session. A modified Delphi method was used assess consensus among the panel.

RESULTS

After 2 rounds of Delphi surveys, 29 statements met criteria for consensus. One statement did not meet consensus. The statements were grouped into several categories to facilitate presentation.

CONCLUSIONS

A standardized approach to UAS for children with Down Syndrome must take into account the unique challenges inherent to treating a complex pediatric population with a high rate of sensory processing disorders. This expert panel has met consensus on several statements that will guide clinicians as this novel therapy is adopted.

Overcoming language barriers in pediatric care: a multilingual, AI-driven curriculum for global healthcare education

Background

Online medical education often faces challenges related to communication and comprehension barriers, particularly when the instructional language differs from the healthcare providers' and caregivers' native languages. Our study addresses these challenges within pediatric healthcare by employing generative language models to produce a linguistically tailored, multilingual curriculum that covers the topics of team training, surgical procedures, perioperative care, patient journeys, and educational resources for healthcare providers and caregivers.

Methods

An interdisciplinary group formulated a video curriculum in English, addressing the nuanced challenges of pediatric healthcare. Subsequently, it was translated into Spanish, primarily emphasizing Latin American demographics, utilizing OpenAI's GPT-4. Videos were enriched with synthetic voice profiles of native speakers to uphold the consistency of the narrative.

Results

We created a collection of 45 multilingual video modules, each ranging from 3 to 8 min in length and covering essential topics such as teamwork, how to improve interpersonal communication, "How I Do It" surgical procedures, as well as focused topics in anesthesia, intensive care unit care, ward nursing, and transitions from hospital to home. Through AI-driven translation, this comprehensive collection ensures global accessibility and offers healthcare professionals and caregivers a linguistically inclusive resource for elevating standards of pediatric care worldwide.

Conclusion

This development of multilingual educational content marks a progressive step toward global standardization of pediatric care. By utilizing advanced language models for translation, we ensure that the curriculum is inclusive and accessible. This initiative aligns well with the World Health Organization's Digital Health Guidelines, advocating for digitally enabled healthcare education.

Bilateral Vocal Cord Paralysis Requiring Long-term Tracheostomy After SARS-CoV-2 Infection

Bilateral vocal cord paralysis can cause obstruction of glottic airflow, resulting in respiratory distress and the need for a surgical airway. We report a case of acute onset bilateral vocal cord paralysis in a healthy adolescent patient 9 days after a mild severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. This 15-year-old patient presented with dyspnea, tachypnea, and stridor. A fiberoptic laryngoscopy revealed bilateral vocal fold paralysis with limited vocal cord abduction causing respiratory distress. A detailed set of diagnostic test results, including blood work, imaging, and a lumbar puncture, were all negative other than her new onset diagnosis of SARS-CoV-2 infection. The patient underwent tracheostomy placement with the subsequent resolution of her symptoms. Her vocal cord function remains impaired, and the patient continues to be tracheostomy-dependent 13 months after the initial presentation. SARS-CoV-2 infection has multiple well-established neurologic complications in children. The current case suggests that vocal cord paralysis may be an additional neuropathic sequela of the virus. Vocal cord pathology should be an important consideration when constructing a differential for children presenting with voice, swallowing, or breathing complaints after SARS-CoV-2 infection.

Challenges and adverse events in pediatric hypoglossal nerve stimulation

INTRODUCTION

Hypoglossal nerve stimulation was recently FDA approved for use in children with Down Syndrome and persistent obstructive sleep apnea. Although there is a robust experience in hypoglossal nerve stimulation in adults, we observed several challenges that are unique to providing this therapy to a complex pediatric population with a high rate of sensory processing disorders. We sought to review the adverse events and challenges to inform clinicians as hypoglossal nerve stimulation becomes a more accessible option for this complex population.

METHODS

Retrospective case series of children with Down Syndrome and persistent OSA who underwent hypoglossal nerve stimulation. Inclusion and exclusion criteria included Down Syndrome, age 10-22 years, persistent severe OSA after adenotonsillectomy (AHI>10 with <25 % central or mixed events), inability to tolerate positive airway pressure, and absence of concentric palatal collapse on sleep endoscopy. Patients were identified and their charts were reviewed. Adverse events and their subsequent management were recorded. The major outcome variable was the total number of adverse events.

RESULTS

A total of 53 patients underwent implantation of a hypoglossal nerve stimulator; 35 (66 %) patients were male and the average age at implantation was 15.1 years (standard deviation 3.0y). A total of 30 adverse events were noted, including 17 nonserious and 13 serious. The most common nonserious complications included temporary tongue discomfort, rash at the surgical site, and cellulitis. Serious complications included readmission (for cellulitis, pain, and device extrusion), reoperation (most commonly for battery depletion) and pressure ulcer formation.

CONCLUSION

Hypoglossal nerve stimulation provides a much-needed therapy for children with DS and persistent OSA after adenotonsillectomy. Although there is a robust experience in providing this treatment to adults, many considerations must be made when adapting this technology to a pediatric population with a high rate of sensory processing disorders.

Upper Esophageal Sphincter Dysfunction in Children with Type 1 Laryngeal Cleft after Failed Primary Cleft Repair

Changes in pharyngeal and upper-esophageal-sphincter (UES) motor dynamics contribute to swallowing dysfunction. Children with type 1 laryngeal clefts can present with swallowing dysfunction and associated symptoms which may persist even after the initial endoscopic intervention. This study sought to characterize pharyngeal and esophageal motor function in children with type 1 laryngeal clefts who had persistent presenting symptoms after their initial therapeutic intervention. We retrospectively analyzed high-resolution esophageal manometry studies of children ≤ 18 years old with type 1 laryngeal clefts who had an esophageal manometry study performed for persistent symptoms after an initial repair. A total of 16 children were found to have significantly increased UES resting pressure, UES pre- and post-swallow maximum pressures, and duration of UES contraction during swallows in comparison to nine age-matched controls of children without pharyngeal anatomical abnormalities. There was no difference between UES residual pressures or pharyngeal dynamics between the two groups. UES resting and residual pressures did not correlate with VFFS in penetration and aspiration scores of children with type 1 laryngeal clefts status post repair. Our study is the first to identify specific changes in UES motor function in patients with type 1 laryngeal cleft post initial repair.

Blue light laser recontouring for pediatric benign fibrovascular vocal fold lesions

INTRODUCTION

Up to 40% of children with hoarseness due to benign fibrovascular vocal fold lesions do not respond to voice therapy and could benefit from further intervention to improve their communication abilities. Currently there are limited surgical options for children too young to comply with post-operative voice rest. We have begun using the 445 nm laser to recontour benign fibrovascular vocal fold lesions without post-operative voice rest in young children with hoarseness due to vocal fold nodules that is unresponsive to voice therapy. This report presents pilot data on the effect of this treatment on pediatric voice-related quality of life.

METHODS

Pediatric patients with benign fibrovascular lesions and severe subjective dysphonia (per parents or teachers) were given the option of undergoing surgery or continuing voice therapy. Those that opted for surgery underwent 445 nm laser recontouring of their vocal folds. They were discharged home the same day with no voice rest required. Pre- and post-demographic, acoustic measures, auditory perceptual assessments, and validated patient quality of life measures were collected.

RESULTS

Four patients (ages 3-8y, all male) were selected for surgery. The mean pre- and post-op PVRQOL scores were 59.4 (range: 22.5-80) and 98.1 (range: 97.5-100), respectively (low scores suggest lower voice-related QOL), and a mean change of 38.8 (previously established minimum clinically important difference: 12). Pre- and post-acoustic and aerodynamic measures similarly reflected this improvement.

CONCLUSION

This pilot case series addresses a commonly seen population (children with benign fibrovascular lesions and significant dysphonia despite voice therapy) where the best practice for timing and types of surgical intervention is unclear. Photoangiolytic lasers (including the 445 nm laser) are gaining popularity for the treatment of benign laryngeal pathologies, and their use may expand treatment possibilities for children with severe dysphonia due to benign vocal fold lesions that do not respond to voice therapy. Further longitudinal investigations are necessary to confirm the safety and efficacy.

Pediatric intraoperative nerve monitoring during thyroid surgery: A review from the American Head and Neck Society Endocrine Surgery Section and the International Neural Monitoring Study Group

Children are more likely to experience recurrent laryngeal nerve (RLN) injury during thyroid surgery. Intraoperative nerve monitoring (IONM) may assist in nerve identification and surgical decision making. A literature review of pediatric IONM was performed and used to inform a monitoring technique guide and expert opinion statements. Pediatric IONM is achieved using a variety of methods. When age-appropriate endotracheal tubes with integrated surface electrodes are not available, an alternative method should be used. Patient age and surgeon experience with laryngoscopy influence technique selection; four techniques are described in detail. Surgeons must be familiar with the nuances of monitoring technique and interpretation; opinion statements address optimizing this technology in children. Adult IONM guidelines may offer strategies for surgical decision making in children. In some cases, delay of second-sided surgery may reduce bilateral RLN injury risk.

Evaluation of the Human Vocal Fold Lamina Propria Development Using Optical Coherence Tomography

OBJECTIVES/HYPOTHESIS

Identifying distinctive features of the vocal fold (VF) during development could have significant clinical implications for treating voice disorders. This study investigates the structural organization of the VF microanatomy across gender and age groups using optical coherence tomography (OCT).

STUDY DESIGN

Prospective clinical trial.

MATERIALS AND METHODS

In vivo OCT images were acquired from 97 patients (58 males and 39 females) aged between 6 weeks and 27 years. All patients showed no signs of vocal fold pathology on endoscopy. Morphological features were extracted from OCT images and statistically compared between age groups. This study was performed at Massachusetts Eye and Ear between 2017 and 2019.

RESULTS

All OCT acquisitions show a stratified microanatomy across age groups, even in newborns suggesting the presence of a superficial lamina propria (SLP) at birth. Furthermore, the optical scattering in the VF lamina propria changes according to age, suggesting subepithelial maturation. Although the epithelium thickness was relatively constant across age groups, the SLP showed a significant linear relationship between age and thickness (P = .016). Furthermore, a significant difference (P = .002) in SLP thickness was found between young adult males and females. The overall thickness of the entire mucosa did not change significantly with age.

CONCLUSION

OCT is a noninvasive imaging modality capable of providing quantitative morphological features to describe the VF development. A stratified structure can be observed in OCT from newborns to young adults. Further investigations could combine OCT, acoustic measurements, and molecular sensitive techniques to provide a complete interpretation of the VF development.

LEVEL OF EVIDENCE

NA Laryngoscope, 131:E2558-E2565, 2021.

International Pediatric Otolaryngology Group (IPOG) management recommendations: Pediatric tracheostomy decannulation

OBJECTIVES

To provide recommendations to otolaryngologists, pulmonologists, and allied clinicians for tracheostomy decannulation in pediatric patients.

METHODS

An iterative questionnaire was used to establish expert recommendations by the members of the International Pediatric Otolaryngology Group.

RESULTS

Twenty-six members completed the survey. Recommendations address patient criteria for decannulation readiness, airway evaluation prior to decannulation, decannulation protocol, and follow-up after both successful and failed decannulation.

CONCLUSION

Tracheostomy decannulation recommendations are aimed at improving patient-centered care, quality and safety in children with tracheostomies.

International Pediatric Otolaryngology Group (IPOG) survey: Efforts to avoid complications in home tracheostomy care

OBJECTIVE

To provide guidance for home care tracheostomy management in the pediatric population. The mission of the IPOG is to develop expertise-based recommendations for the management of pediatric otolaryngologic disorders with the goal of improving patient care.

METHODS

Survey of expert opinion by the members of the International Pediatric Otolaryngology Group (IPOG).

RESULTS

Survey results provide guidance for caregiver teaching, the reuse of tracheostomies and suction catheters while inpatient and following discharge, acceptable sterilization practices for tracheostomies, tracheitis workup and management, and outpatient follow-up practices.

CONCLUSION

This presentation of common home tracheostomy care practices are aimed at improving patient-centered care in the pediatric population.

Quantitative evaluation of the human vocal fold extracellular matrix using multiphoton microscopy and optical coherence tomography

Identifying distinct normal extracellular matrix (ECM) features from pathology is of the upmost clinical importance for laryngeal diagnostics and therapy. Despite remarkable histological contributions, our understanding of the vocal fold (VF) physiology remains murky. The emerging field of non-invasive 3D optical imaging may be well-suited to unravel the complexity of the VF microanatomy. This study focused on characterizing the entire VF ECM in length and depth with optical imaging. A quantitative morphometric evaluation of the human vocal fold lamina propria using two-photon excitation fluorescence (TPEF), second harmonic generation (SHG), and optical coherence tomography (OCT) was investigated. Fibrillar morphological features, such as fiber diameter, orientation, anisotropy, waviness and second-order statistics features were evaluated and compared according to their spatial distribution. The evidence acquired in this study suggests that the VF ECM is not a strict discrete three-layer structure as traditionally described but instead a continuous assembly of different fibrillar arrangement anchored by predominant collagen transitions zones. We demonstrated that the ECM composition is distinct and markedly thinned in the anterior one-third of itself, which may play a role in the development of some laryngeal diseases. We further examined and extracted the relationship between OCT and multiphoton imaging, promoting correspondences that could lead to accurate 3D mapping of the VF architecture in real-time during phonosurgeries. As miniaturization of optical probes is consistently improving, a clinical translation of OCT imaging and multiphoton imaging, with valuable qualitative and quantitative features, may have significant implications for treating voice disorders.

Quantifying the benefits from a care coordination program for tracheostomy placement in neonates

OBJECTIVE

Value-based care models are becoming instrumental in structuring clinical care delivery in our healthcare climate. Our objective was to determine the value associated with implementation of a Family-Centered Care Coordination (FCCC) program for neonates undergoing tracheostomy.

METHODS

A multi-disciplinary FCCC program was implemented at the Massachusetts Eye and Ear Infirmary and MassGeneral Hospital for Children in January 2013. This program is designed to ensure a safe transition out of the hospital for children undergoing tracheostomy, reduce re-admission rates, and increase caregiver quality of life (QOL). Study participants included neonates undergoing tracheostomy in 2012 and 2015. This retrospective cohort study examined length of stay (LOS), utilized time-driven activity-based costing to estimate the cost of care, assessed caregiver QOL with 1-month Pediatric Tracheostomy Health Status Instrument (PTHSI) scores, and assessed complications with 6-month Medical Complications Associated with Pediatric Tracheostomy (MCAT) scores.

RESULTS

Following implementation of the FCCC program, average LOS decreased from 30.5 days (range 17-39) to 16.6 days (range 9-23). The largest process improvement (cost reduction of 61%) occurred in the discharge-planning phase. The overall cost per care cycle was reduced by 36%. A large clinically meaningful benefit was demonstrated for PTHSI (effect size 0.80) as well as MCAT scores (effect size 9.35).

CONCLUSIONS

We demonstrated the higher outcomes, including reductions in caregiver burden and complication rates, and the lower costs associated with implementation of the FCCC program for neonates undergoing tracheostomy.

Comparison of Ibuprofen vs Acetaminophen and Severe Bleeding Risk After Pediatric Tonsillectomy: A Noninferiority Randomized Clinical Trial

Importance

Ibuprofen is an effective analgesic after tonsillectomy alone or tonsillectomy with adenoidectomy, but concerns remain about whether it increases postoperative hemorrhage.

Objective

To investigate the effect of ibuprofen compared with acetaminophen on posttonsillectomy bleeding (PTB) requiring surgical intervention in children.

Design, Setting, and Participants

A multicenter, randomized, double-blind noninferiority trial was conducted at 4 tertiary medical centers (Massachusetts Eye and Ear Infirmary, Boston; Naval Medical Center, San Diego, California; Naval Medical Center, Portsmouth, Virginia; Madigan Army Medical Center, Tacoma, Washington). A total of 1832 children were assessed for eligibility (presence of sleep-disordered breathing or obstructive sleep apnea, adenotonsillar hypertrophy, or infectious tonsillitis undergoing extracapsular tonsillectomy by electrocautery). Of these, 1091 were excluded because they did not meet eligibility criteria (n = 681) or refused to participate (n = 410); thus, 741 children aged 2 to 18 years undergoing tonsillectomy alone or tonsillectomy with adenoidectomy were enrolled between May 3, 2012, and January 20, 2017.

Interventions

Participants were randomized to receive ibuprofen, 10 mg/kg (n = 372), or acetaminophen, 15 mg/kg (n = 369), every 6 hours for the first 9 postoperative days.

Main Outcomes and Measures

Rate and severity of posttonsillectomy bleeding were recorded using a postoperative bleeding severity scale: type 1 (bleeds that were observed at home or evaluated in the emergency department without further intervention), type 2 (bleeds that required readmission for observation), and type 3 (bleeds that required a return to the operating room for control of hemorrhage). Type 3 bleeding was the main outcome measure. The noninferiority margin was set at 3%, and modified intention-to-treat analysis was used.

Results

Of the 741 children enrolled, 688 children (92.8%) (median [interquartile range] age, 5 [4] years; 366 boys [53.2%]) received the study medication and were included in a modified intention-to-treat analysis. The rate of bleeding requiring operative intervention was 1.2% in the acetaminophen group and 2.9% in the ibuprofen group (difference, 1.7%; 97.5% CI upper limit, 3.8%; P = .12 for noninferiority). There were no significant adverse events or deaths.

Conclusions and Relevance

This study could not exclude a higher rate of severe bleeding in children receiving ibuprofen after tonsillectomy alone or tonsillectomy with adenoidectomy. This finding should be considered when selecting a postoperative analgesic regimen. Further studies are needed to understand if bleeding risk is affected when ibuprofen is used for a shorter duration or in combination with acetaminophen for postoperative analgesia.

Trial Registration

ClinicalTrials.gov identifier: NCT01605903.

International Pediatric Otolaryngology Group (IPOG): Juvenile-onset recurrent respiratory papillomatosis consensus recommendations

OBJECTIVES

To develop consensus recommendations for the evaluation and management of juvenile-onset recurrent respiratory papillomatosis (JORRP) in pediatric patients.

METHODS

Expert opinion by the members of the International Pediatric Otolaryngology Group (IPOG). The mission of the IPOG is to develop expertise-based consensus recommendations for the management of pediatric otolaryngologic disorders with the goal of improving patient care. The consensus recommendations herein represent the first publication by the group.

RESULTS

Consensus recommendations including diagnostic considerations, surgical management, systemic adjuvant therapies, postoperative management, surveillance, and voice evaluation. These recommendations are based on the collective opinion of the IPOG members and are targeted for otolaryngologists, primary care providers, pulmonologists, infectious disease specialists, and any other health care providers that manage patients with JORRP.

CONCLUSIONS

Pediatric JORRP consensus recommendations are aimed at improving care and outcomes in this patient population.

Utility of Optical Coherence Tomography for Guiding Laser Therapy Among Patients With Recurrent Respiratory Papillomatosis

Importance

Recurrent respiratory papillomatosis (RRP) is a viral-induced disease caused by human papillomavirus and the second leading cause of dysphonia in children; however, neither a cure nor a definitive surgical treatment is currently available for RRP. Although laser therapy is often used in the treatment of RRP, the lack of real-time laser-tissue interaction feedback undermines the ability of physicians to provide treatments with low morbidity. Therefore, an intraoperative tool to monitor and control laser treatment depth is needed.

Objective

To investigate the potential of combining optical coherence tomography (OCT) with laser therapy for patient-tailored laryngeal RRP treatments.

Design, Setting, and Participants

This in vivo study was performed at the Massachusetts Eye and Ear Infirmary from February 1, 2017, to September 1, 2017. Three-dimensional OCT images were acquired before, during, and after photoangiolytic laser therapy in 10 pediatric patients with a history of papilloma growth who presented with lesions and hoarseness.

Main Outcomes and Measures

Whether intraoperative OCT monitoring of changes in optical scattering and absorption provides quantitative information to control thermal damage in tissue.

Results

Among the 10 pediatric patients (age range, 4-11 years; 6 male) included in the study, high-resolution OCT images revealed epithelial hyperplasia with clear RRP lesion margins. Images acquired during therapy indicated coagulation deep in tissue, and posttherapy images showed the ability to quantify the amount of tissue ablated by the photoangiolytic laser.

Conclusions and Relevance

Concurrent use of OCT imaging and laser therapy may improve postoperative outcomes for patients with RRP by delivering an optimal, patient-tailored treatment. Additional studies investigating the correlation between optical properties with vocal outcomes are required.

Indirect vs Direct Voice Therapy for Children With Vocal Nodules: A Randomized Clinical Trial

Importance

Benign vocal fold nodules affect 12% to 22% of the pediatric population, and 95% of otolaryngologists recommend voice therapy as treatment. However, no randomized clinical trials that we are aware of have shown its benefits.

Objective

To determine the impact of voice therapy in children with vocal fold nodules according to pretherapy and posttherapy scores on the Pediatric Voice-Related Quality of Life (PVRQOL) survey; secondary objectives included changes in phonatory parameters.

Design, Setting, and Participants

For this multicenter randomized clinical trial, 114 children ages 6 to 10 years with vocal fold nodules, PVRQOL scores less than 87.5, and dysphonia for longer than 12 weeks were recruited from outpatient voice and speech clinics. This age range was identified because these patients have not experienced pubertal changes of the larynx, tolerate stroboscopy, and cooperate with voice therapy. Participants were blinded to treatment arm.

Interventions

Participants received either indirect or direct therapy for 8 to 12 weeks. Indirect therapy focused on education and discussion of voice principles, while direct treatment used the stimulus, response, antecedent paradigm.

Main Outcomes and Measures

The primary outcome measure was PVRQOL score change before and after treatment. Secondary phonatory measures were also compared.

Results

Overall, 114 children were recruited for study (mean [SD] age, 8 [1.4] years; 83 males [73%]); with 57 randomized to receive either indirect or direct therapy. Both direct and indirect therapy approaches showed significant differences in PVRQOL scores pretherapy to posttherapy. The mean increase in PVRQOL score for direct therapy was 19.2, and 14.7 for indirect therapy (difference, 4.5; 95.3% CI, -10.8 to 19.8). Of 44 participants in the direct therapy group, 27 (61%) achieved a clinically meaningful PVRQOL improvement, compared with 26 of 49 (53%) for indirect therapy (difference, 8%; 95% CI, -12 to 28). Post hoc stratification showed robust effects in the direct therapy group for older children (Cohen d = 0.50) and the latter two-thirds of participants (Cohen d = 0.46). Vocal fold nodules reduced in size in 31% (22 of 70) and completely resolved in 11% (8 of 70) of participants who consented to a second set of images after going through the recruitment process.

Conclusions and Relevance

Both direct and indirect voice therapy improved voice-related quality of life in children with vocal fold nodules, although there was no significant difference between approaches. Future studies may focus upon which voice therapy approaches are effective in treating age-defined populations.

Trial Registration

clinicaltrials.gov Identifier: NCT01255735.

International Pediatric Otolaryngology Group (IPOG) consensus recommendations: Diagnosis, pre-operative, operative and post-operative pediatric choanal atresia care

OBJECTIVE

To provide recommendations to otolaryngologists and allied physicians for the comprehensive management of young infants who present with signs or symptoms of choanal atresia.

METHODS

A two-iterative delphi method questionnaire was used to establish expert recommendations by the members of the International Otolaryngology Group (IPOG), on the diagnostic, intra-operative, post-operative and revision surgery considerations.

RESULTS

Twenty-eight members completed the survey, in 22 tertiary-care center departments representing 8 countries. The main consensual recommendations were: nasal endoscopy or fiberscopy and CT imaging are recommended for diagnosis; unilateral choanal atresia repair should be delayed after at least age 6 months whenever possible; transnasal endoscopic repair is the preferred technique; long term follow-up is recommended (minimum one year) using nasal nasofiberscopy or rigid endoscopy, without systematic imaging.

CONCLUSION

Choanal atresia care consensus recommendations are aimed at improving patient-centered care in neonates, infants and children with choanal atresia.

Pharyngeal flap using carotid artery mobilization in 22q11.2 deletion syndrome with velopharyngeal insufficiency

INTRODUCTION

22q11.2 deletion syndrome is the most common microdeletion syndrome in children. Many patients with this disease develop craniofacial defects including cleft palate, bifid uvula, and velopharyngeal insufficiency. Our study adds to the current body of literature by describing a novel technique of carotid mobilization performed in conjunction with pharyngeal flap surgery in patients with extensive medialization of the carotid artery.

METHODS

Carotid artery mobilization followed by insertion of a superiorly based pharyngeal flap was performed on two patients, a 10-year-old girl and a 5-year-old boy, with 22q11.2 deletion syndrome concurrent with velopharyngeal insufficiency.

RESULTS

Neither patient experienced significant post-operative issues. Following the procedure, parents of both patients noted significant speech and voice improvement. Both patients had improvements in VPI Effects On Life Outcome (VELO) scores, nasometry, and production of paragraph passages following surgery.

CONCLUSIONS

Our study describes a novel surgical treatment for children with 22q11.2 deletion syndrome with significant velopharyngeal insufficiency (VPI). The procedure wherein is characterized by an extensive mobilization of the carotid artery followed by implantation of a pharyngeal flap. This technique resulted in no significant intra-operative bleeding, and was measured to be successful as noted by nasometry scores and changes in pre- and post-op VELO scores.

The diagnostic role of triple endoscopy in pediatric patients with chronic cough

OBJECTIVE/HYPOTHESIS

Multi-disciplinary aero-digestive centers provide high quality health care through improved outcomes and treatment costs over separate sub specialty clinics. These outcomes are often the result of a common investigative tool known as triple endoscopy: a rigid bronchoscopy performed by an otolaryngologist, flexible bronchoscopy and lavage obtained by a pulmonologist, and an endoscopy with guided biopsies performed by a gastroenterologist. Combining such procedures into one 'triple endoscopy' allows for diagnoses which otherwise might have been missed with just one procedure. The goal of our study was to describe the efficacy of the triple endoscopy procedure in diagnosing recalcitrant aero-digestive conditions, specifically chronic cough.

STUDY DESIGN

Retrospective chart review METHODS: Multiple charts from children who underwent the triple endoscopy for chronic cough were retrospectively reviewed from 2005 and 2017. Complete data from the triple procedure was gathered on 243 patients, including findings by sub specialty (otolaryngology, pulmonology, and gastroenterology).

RESULTS

Of the 243 patients with complete data who underwent triple endoscopy, 203 (83.5%) children had at least one positive finding. Of these children, 101 (41.5%) had one specialty specific diagnosis, and 102 (42%) had multiple cross specialty diagnoses. When describing the diagnoses, 63 children had gastro esophageal reflux (GER), 14 had eosinophilic esophagitis (EoE), 118 had tracheomalacia, 54 had laryngeal clefts, and 102 children had positive bronchoalveolar lavages. Outcome data was available on 226 patients (93%), of these patients, 188 patients had a diagnosis from the triple scope. Of those patients with a diagnosis and outcome data, 144 (76.6%) children had an improved outcome as a result of a treatment plan targeting that diagnosis, while 16 of the 37 patients without a diagnosis improved. This difference was significant by chi square analysis (p<0.0001).

CONCLUSION

The triple scope procedure is a useful investigative tool for patients with recalcitrant aero-digestive complaints like chronic cough. In particular, triple scope can yield more than one specialty specific diagnosis, normally missed by one procedure. The triple scope also leads to improved parental satisfaction by improved cost and healthcare outcomes.

Aspiration and Dysphagia in the Neonatal Patient

Dysphagia and aspiration are commonly encountered problems in the neonatal population. It is often multifactorial in nature and management should be tailored to the individual patient. Multiple causes should be considered, including anatomic abnormalities, neurologic/developmental delay, cardiopulmonary disease/infection, and gastroesophageal reflux disease, in addition to those cases where a definitive reason may not be identified. Management should be multidisciplinary in nature and surgical intervention may be indicated in certain populations of patients. Here, we discuss the presentation, workup, and management of the neonatal patient with dysphagia and aspiration.

Clinical and surgical implications of intraoperative optical coherence tomography imaging for benign pediatric vocal fold lesions

INTRODUCTION

Benign vocal disorders in children include an extensive list of abnormalities creating a variety of debilitating levels of dysphonia. Precise delineation of the benign lesion type and margins may have significant public health implications in children. An innovative technology such as optical coherence tomography (OCT) is being explored to delineate pediatric benign laryngeal lesions. An accurate assessment of the subepithelial morphology may help towards tailoring more personalized therapeutic treatments. This study was established to highlight key morphological and optical features of benign pediatric laryngeal lesions using intraoperative OCT and to suggest clinical implications that arise from such optical imaging.

METHODS AND MATERIALS

This in vivo study was performed at Massachusetts Eye and Ear Infirmary. Intraoperative imaging was performed on twenty-five pediatric patients ranging from 1 year to 16 years of age presenting hoarseness. Three-dimensional OCT images of benign laryngeal lesions or a subsite of the lesion were acquired.

RESULTS

High-resolution OCT images of 25 patients with benign laryngeal lesions such as nodules, cysts, Reinke's edema, vocalis sulcus, and papilloma revealed distinct and specific morphological differences with normal tissue. Nodules show a symmetrical superficial remodeling of the vocal fold epithelial layer and the basement membrane. Cysts have oval-like shape and are either superficial or deeply located in the lamina propria. Sulcus vocalis OCT imaging allows characterizing if the lesion is shallow or deep according to Ford's classification system. Reinke's edema of the mucosa can be observed and quantified, which may lead to suspicion on the underlying social and medical conditions. Finally, the ability to assess margins and depth of invasion of papilloma lesions is demonstrated, raising the possibility to use OCT with angiolytic lasers for patient-tailored treatments.

CONCLUSIONS

OCT imaging of benign pediatric vocal lesions is promising as it could improve preoperative decision-making and possibly peroperative imaging-guidance for patient-tailored treatments. An assessment of the optical contrast between healthy and abnormal tissue may help towards a more qualitative and quantitative approach to current standard care, especially when diagnosis remains unclear.

A quality study of family-centered care coordination to improve care for children undergoing tracheostomy and the quality of life for their caregivers

IMPORTANCE

Approximately 4000 U.S. children undergo tracheostomy yearly [1], and these surgeries often result in hospital re-admissions that have definite cost and caregiver burdens due to complications that are avoidable with proper training and support.

OBJECTIVE

To assess the impact of a Family-Centered Care Coordination (FCCC) program on the quality of care received by children undergoing tracheostomy and their caregivers.

DESIGN

Caregivers of children undergoing tracheostomies from January 2012 to January 2013 and then a different set of caregivers of children undergoing tracheostomies from January 2015 to January 2016 completed both the Pediatric Tracheostomy Health Status Instrument (PTHSI) 1 month after discharge and the Medical Complications Associated with Pediatric Tracheostomy (MCAT) questionnaire 6 months after initial tracheostomy. To assess complication rates, these same sets of caregivers were asked to complete the MCAT and only those who provided complete medical data for all 6 months were included for comparative analysis.

SETTING

The PTHSI and MCAT were administered at Massachusetts Eye and Ear in a hospital setting.

PARTICIPANTS

Ten caregivers of children undergoing tracheostomies completed the PTHSI before FCCC program implementation and12 caregivers then completed the PTHSI after FCCC implementation. For each of the 2 groups, 5 caregivers provided complete data on the MCAT questionnaires.

EXPOSURES

FCCC is a collection of programs, policies, and tools designed to ensure safe transition home for children undergoing tracheostomies, reduce re-admission rates, and minimize "caregiver burden".

MAIN OUTCOMES AND MEASURES

The PTHSI is a validated caregiver quality of life instrument that was supplemented by the MCAT which records post-discharge medical issues following tracheostomy that relate specifically to the tracheotomy placement.

RESULTS

The time to first follow-up appointment decreased from 6.4 weeks (SD = 1.52) to 6 days (SD = 0.18) with FCCC implementation. The total MCAT scores decreased from 15.2 (SD = 1.1) to 1.3 (SD = 1.3) (Wilcoxon sum rank test: P < 0.016) whereas neither PTHSI scores (P = 0.32) nor the specific caregiver burden domain (P = 0.18) demonstrated a significant change.

CONCLUSIONS

and Relevance: By reducing the time to first follow-up after tracheostomy and by optimizing caregiver tracheostomy tube care and teaching, children's quality of care and caregiver burden can be significantly improved.

Assessment of the feeding Swallowing Impact Survey as a quality of life measure in children with laryngeal cleft before and after repair

OBJECTIVE

To cross-validate the Feeding Swallowing Impact Survey (FSIS), a quality of life instrument, specifically to a subpopulation of children who aspirate due to laryngeal cleft.

INTRODUCTION

The FSIS is a recently validated instrument used to describe caregiver quality of life (QOL) in children with aspiration due to various causes. To cross-validate the FSIS specifically to the subpopulation of children who aspirate due to laryngeal cleft, we tested the hypotheses that caregivers would report significant different scores form baseline if their children improved at the one year mark postintervention due to either successful conservative or surgical measures (discriminant validity) and would not report significant differences in their FSIS reporting if there was no change in their child's aspiration at the one year mark post intervention (convergent validity).

METHODS

The FSIS was administered to the caregivers of 35 children (19 male, 16 female; age range: 5-79 months) who aspirate secondary to known laryngeal cleft (diagnosed by suspension laryngoscopy and inspection). All children had a baseline VFSS demonstrating aspiration and documenting what feeding plan to follow and caregivers completed the FSIS at this point as well. All children regardless of whether they were treated by conservative or surgical intervention underwent a follow-up VFSS at the one year post-intervention mark and the caregivers completed a FSIS at this time point as well.

RESULTS

Among two distinct sub-populations of children who underwent either successful conservative or surgical treatment for their laryngeal cleft and demonstrated improvement at the one year mark (as defined by a VFSS documented decreased need for thickener by at least one consistency or more) and where we hypothesized that FSIS scores would not be significantly different, the caregivers reported no significant differences in FSIS scores cleft repair (mean FSIS scores 2.45 (SD 0.88)/2.1 (SD 0.94); p = 0.28). Moreover, as another test to convergent validity, for children who underwent either unsuccessful conservative treatment (and subsequently went on to need surgery) or who were not successfully surgically treated for their laryngeal cleft and demonstrated no significant improvement at the one year mark (as defined by a VFSS documented decreased need for thickener by at least one consistency or more), the caregivers reported no significant differences in FSIS scores cleft repair (mean FSIS scores 2.8(SD 0.79)/2.5(SD 0.88); p = 0.69). For divergent validity, two distinct sub-populations of children who underwent either successful or not successful surgical treatment for their laryngeal cleft (demonstrated by either improvement or lack of improvement at the one year mark VFSS as defined by a decreased need for thickener by at least one consistency or more) revealed significant differences in caregiver FSIS scores cleft repair (mean FSIS scores 1.38 (SD 0.32); 32.8 (SD 0.79); p=<0.0002).

DISCUSSION

This results of this study provide convergent and divergent validity supporting the cross-validation of the FSIS instrument to be utilized as a validated QOL instrument to evaluate children with aspiration specifically due laryngeal cleft as another tool with which to evaluate the outcomes of medical or surgical interventions for this disorder.

PD-L1 expression and CD8+ infiltration shows heterogeneity in juvenile recurrent respiratory papillomatosis

INTRODUCTION

Tumor immunotherapy have broadened therapeutic options for tumor treatment. The role of immune function in juvenile recurrent respiratory papillomatosis (JRRP) has not been investigated. Applying immunoblockade inhibitors as a novel disease treatment is unclear. Our study, for the first time, evaluates immune infiltration and immuno-suppressive molecule expression in JRRP. Our study provides insights in possibly treating this disease with tumor immunotherapies. We aimed to determine expression of programmed death-ligand 1 (PD-L1), a cancer escape protein, and presence of CD8+ T cell infiltration in tumor microenvironment.

MATERIAL AND METHODS

Seven patients with JRRP (mean age: 7.43; age range 3-17) in this study routinely have their tumors surgical debulked at Massachusetts Eye and Ear Infirmary. Following surgery, samples were de-identified and sent to pathology where they were stained and analyzed.

RESULTS

Six out of seven patients expressed PD-L1 on tumor cells to various extents. Three patients showed concurrent PD-L1 expression on tumor cells and abundant CD8+ tumor infiltrating lymphocytes as well as PD-L1+ stromal lymphocytes, while PD-L1 expression on tumor cells were not associated with CD8+ tumor infiltrating T cells nor PD-L1+ stromal lymphocytes in the other three patients. HPV 6/11 and p16 was detected in all the patients. There appeared to be no correlation between either PD-L1 expression and CD8+ infiltration and clinical severity as measured by both the number of surgeries per year or Derkay score.

CONCLUSIONS

Despite a small cohort, the expression of p16 and HPV 6/11 in all of the patients confirms the tissues were HPV tumor cells. PD-L1 expression was detected in the vast majority of tumor samples, while inflammatory cell compartments showed a higher degree of variation. Expression of PD-L1 on tumor cells but not inflammatory cells raises the possibility of a tumor cell intrinsic manner of PD-L1 expression. In contrast, a group of patients showed PD-L1 positivity in both tumor and inflammatory cells along with abundant CD8+ tumor infiltrating lymphocytes, suggesting adoptive immune resistance in these tumors and potential benefits from tumor immunotherapy.

Radiation exposure from videofluoroscopic swallow studies in children with a type 1 laryngeal cleft and pharyngeal dysphagia: A retrospective review

INTRODUCTION

Radiation exposure is recognized as having long term consequences, resulting in increased risks over the lifetime. Children, in particular, have a projected lifetime risk of cancer, which should be reduced if within our capacity. The objective of this study is to quantify the amount of ionizing radiation in care for children being treated for aspiration secondary to a type 1 laryngeal cleft. With this baseline data, strategies can be developed to create best practice pathways to maintain quality of care while minimizing radiation exposure.

METHODS

Retrospective review of 78 children seen in a tertiary pediatric aerodigestive center over a 5 year period from 2008 to 2013 for management of a type 1 laryngeal cleft. The number of videofluoroscopic swallow studies (VFSS) per child was quantified, as was the mean effective dose of radiation exposure. The 78 children reviewed were of mean age 19.9 mo (range 4 mo-12 years). All children were evaluated at the aerodigestive center with clinical symptomatology and subsequent diagnosis of a type 1 laryngeal cleft. Aspiration was assessed via VFSS and exposure data collected. Imaging exams where dose parameters were not available were excluded.

RESULTS

The mean number of VFSS each child received during the total course of treatment was 3.24 studies (range 1-10). The average effective radiation dose per pediatric VFSS was 0.16 mSv (range: 0.03 mSv-0.59 mSv) per study. Clinical significance was determined by comparison to a pediatric CXR. At our facility a CXR yields an effective radiation dose of 0.017 mSv. Therefore, a patient receives an equivalent total of 30.6 CXR over the course of management.

CONCLUSIONS

Radiation exposure has known detrimental effects particularly in pediatric patients. The total ionizing radiation from VFSS exams over the course of management of aspiration has heretofore not been reported in peer reviewed literature. With this study's data in mind, future developments are indicated to create innovative clinical pathways and limit radiation exposure.

Quality improvement utilizing in-situ simulation for a dual-hospital pediatric code response team

OBJECTIVE

Given the rarity of in-hospital pediatric emergency events, identification of gaps and inefficiencies in the code response can be difficult. In-situ, simulation-based medical education programs can identify unrecognized systems-based challenges. We hypothesized that developing an in-situ, simulation-based pediatric emergency response program would identify latent inefficiencies in a complex, dual-hospital pediatric code response system and allow rapid intervention testing to improve performance before implementation at an institutional level.

METHODS

Pediatric leadership from two hospitals with a shared pediatric code response team employed the Institute for Healthcare Improvement's (IHI) Breakthrough Model for Collaborative Improvement to design a program consisting of Plan-Do-Study-Act cycles occurring in a simulated environment. The objectives of the program were to 1) identify inefficiencies in our pediatric code response; 2) correlate to current workflow; 3) employ an iterative process to test quality improvement interventions in a safe environment; and 4) measure performance before actual implementation at the institutional level.

RESULTS

Twelve dual-hospital, in-situ, simulated, pediatric emergencies occurred over one year. The initial simulated event allowed identification of inefficiencies including delayed provider response, delayed initiation of cardiopulmonary resuscitation (CPR), and delayed vascular access. These gaps were linked to process issues including unreliable code pager activation, slow elevator response, and lack of responder familiarity with layout and contents of code cart. From first to last simulation with multiple simulated process improvements, code response time for secondary providers coming from the second hospital decreased from 29 to 7 min, time to CPR initiation decreased from 90 to 15 s, and vascular access obtainment decreased from 15 to 3 min. Some of these simulated process improvements were adopted into the institutional response while others continue to be trended over time for evidence that observed changes represent a true new state of control.

CONCLUSIONS

Utilizing the IHI's Breakthrough Model, we developed a simulation-based program to 1) successfully identify gaps and inefficiencies in a complex, dual-hospital, pediatric code response system and 2) provide an environment in which to safely test quality improvement interventions before institutional dissemination.

International Pediatric Otolaryngology Group (IPOG) consensus recommendations: Routine peri-operative pediatric tracheotomy care

OBJECTIVES

To develop consensus recommendations for peri-operative tracheotomy care in pediatric patients.

METHODS

Expert opinion by the members of the International Pediatric Otolaryngology Group (IPOG). The mission of the IPOG is to develop expertise-based consensus recommendations for the management of pediatric otolaryngologic disorders with the goal of improving patient care. The consensus recommendations herein represent the first publication by the group.

RESULTS

Consensus recommendations including pre-operative, intra-operative, and post-operative considerations, as well as sedation and nutrition management are described. These recommendations are based on the collective opinion of the IPOG members and are targeted to (i) otolaryngologists who perform tracheotomies on pediatric patients, (ii) intensivists who are involved in the shared-care of these patients, and (iii) allied health professionals.

CONCLUSION

Pediatric peri-operative tracheotomy care consensus recommendations are aimed at improving patient-centered care in this patient population.

International Pediatric ORL Group (IPOG) laryngomalacia consensus recommendations

OBJECTIVE

To provide recommendations for the comprehensive management of young infants who present with signs or symptoms concerning for laryngomalacia.

METHODS

Expert opinion by the members of the International Pediatric Otolaryngology Group (IPOG).

RESULTS

Consensus recommendations include initial care and triage recommendations for health care providers who commonly evaluate young infants with noisy breathing. The consensus statement also provides comprehensive care recommendations for otolaryngologists who manage young infants with laryngomalacia including: evaluation and treatment considerations for commonly debated issues in laryngomalacia, initial work-up of infants presenting with inspiratory stridor, treatment recommendations based on disease severity, management of the infant with feeding difficulties, post-surgical treatment management recommendations, and suggestions for acid suppression therapy.

CONCLUSION

Laryngomalacia care consensus recommendations are aimed at improving patient-centered care in infants with laryngomalacia.

Identification of distinct layers within the stratified squamous epithelium of the adult human true vocal fold

OBJECTIVES/HYPOTHESIS

A precise molecular schema for classifying the different cell types of the normal human vocal fold epithelium is lacking. We hypothesize that the true vocal fold epithelium has a cellular architecture and organization similar to that of other stratified squamous epithelia including the skin, cornea, oral mucosa, and esophagus. In analogy to disorders of the skin and gastrointestinal tract, a molecular definition of the normal cell types within the human vocal fold epithelium and a description of their geometric relationships should serve as a foundation for characterizing cellular changes associated with metaplasia, dysplasia, and cancer.

STUDY DESIGN

Qualitative study with adult human larynges.

METHODS

Histologic sections of normal human laryngeal tissue were analyzed for morphology (hematoxylin and eosin) and immunohistochemical protein expression profile, including cytokeratins (CK13 and CK14), cornified envelope proteins (involucrin), basal cells (NGFR/p75), and proliferation markers (Ki67).

RESULTS

We demonstrated that three distinct cell strata with unique marker profiles are present within the stratified squamous epithelium of the true vocal fold. We used these definitions to establish that cell proliferation is restricted to certain cell types and layers within the epithelium. These distinct cell types are reproducible across five normal adult larynges.

CONCLUSION

We have established that three layers of cells are present within the normal adult stratified squamous epithelium of the true vocal fold. Furthermore, replicating cell populations are largely restricted to the parabasal strata within the epithelium. This delineation of distinct cell populations will facilitate future studies of vocal fold regeneration and cancer.

LEVEL OF EVIDENCE

N/A.

Quantitative distinction of unique vocal fold subepithelial architectures using optical coherence tomography

OBJECTIVES

The primary objective of this study was to quantitatively analyze ex vivo porcine, fetal human, and adult human vocal folds by use of optical coherence tomography (OCT). A secondary objective was to quantitatively discriminate among 1-, 2-, and 3-layer lamina propria structures.

METHODS

We performed an analysis of the vocal folds of 10 adult pig, 3 adult human, and 2 fetal human vocal fold specimens using OCT and histologic techniques. We present a quantitative comparison of the OCT results and histologic findings.

RESULTS

We found that OCT allowed for the visualization of the subepithelial vocal fold architecture of all imaged tissue, and that it revealed distinct characteristic signal intensities for each type of specimen.

CONCLUSIONS

Optical coherence tomography was developed for in vivo imaging of biological microstructures. This study demonstrates the ability of OCT to differentiate between the vocal fold architectures of 3 histologically distinct types of vocal folds. Future studies aim to develop a quantitative optical imaging algorithm that can be used to facilitate an in vivo longitudinal clinical investigation of the changes that occur in this layered structure over time and maturation.

Clinical consensus statement: tracheostomy care

OBJECTIVE

This clinical consensus statement (CCS) aims to improve care for pediatric and adult patients with a tracheostomy tube. Approaches to tracheostomy care are currently inconsistent among clinicians and between different institutions. The goal is to reduce variations in practice when managing patients with a tracheostomy to minimize complications.

METHODS

A formal literature search was conducted to identify evidence gaps and refine the scope of this consensus statement. The modified Delphi method was used to refine expert opinion and facilitate a consensus position. Panel members were asked to complete 2 scale-based surveys addressing different aspects of pediatric and adult tracheostomy care. Each survey was followed by a conference call during which results were presented and statements discussed.

RESULTS

The panel achieved consensus on 77 statements; another 39 were dropped because of lack of consensus. Consensus was reached on statements that address initial tracheostomy tube change, management of emergencies and complications, prerequisites for decannulation, management of tube cuffs and communication devices, and specific patient and caregiver education needs.

CONCLUSION

The consensus panel agreed on statements that address the continuum of care, from initial tube management to complications in children and adults with a tracheostomy. The panel also highlighted areas where consensus could not be reached and where more research is needed. This consensus statement should be used by physicians, nurses, and other stakeholders caring for patients with a tracheostomy.

Severe glottic stenosis in a parturient with ectodermal dysplasia

Airway stenosis in pregnancy is challenging and the literature does not offer consensus regarding its evaluation and anesthetic management. A 21-year-old nulliparous woman with ectodermal dysplasia and severe glottic stenosis was referred to the obstetric anesthesia team for evaluation and peripartum management recommendations. She had a history of a congenital complete glottic web that required a tracheostomy at birth. After decannulation at age four, she was lost to follow-up. On examination in early pregnancy, she was found to have a dangerously narrow airway with fixed vocal cords and a glottic aperture of 2-3mm. At nine weeks of gestation an elective tracheostomy was performed under local anesthesia. She later underwent an uneventful cesarean delivery under spinal anesthesia. Ultimately, early interdisciplinary planning for an elective tracheostomy helped assure patient safety during advancing pregnancy and delivery.

Pediatric paradoxical vocal-fold motion: presentation and natural history

OBJECTIVES

To describe (1) a cohort of children with paradoxical vocal-fold motion (PVFM) who were referred to a multidisciplinary airway center and (2) the outcomes of various treatment modalities including speech therapy, gastroesophageal reflux disease treatment, and psychiatric treatment.

PATIENTS AND METHODS

This was a case series with chart review of children younger than 18 years with PVFM evaluated at a tertiary care pediatric airway center over a 36-month period.

RESULTS

Fifty-nine children with PVFM were evaluated. The cohort had a mean age of 13.64 years (range: 8-18 years) and a female-to-male ratio of 3:1. Speech therapy as an initial treatment resulted in a 63% (24 of 38) success rate after an average of 3.7 treatment sessions. Speech therapy was a more successful treatment than antireflux therapy (P = .001). Ten percent (6 of 59) of the children presented with a known psychiatric diagnosis, and 30% (18 of 59) of children in the cohort were ultimately diagnosed with a psychiatric condition. Children with inspiratory stridor at rest had a lower initial success rate with speech therapy (56%), a higher rate of underlying psychiatric disorders (75%), and a high rate of success after psychiatric treatment (100%) that required, on average, 3 sessions over a 2-month period.

CONCLUSIONS

To our knowledge, this is the largest study to date on pediatric PVFM. The majority of children with PVFM improve with speech therapy. Children with PVFM at rest may be better treated with psychiatric therapy than speech therapy. Furthermore, children who present with symptoms at rest may have a higher likelihood of underlying psychiatric disease.

Pediatric laryngeal diadochokinetic rates: establishing a normative database

OBJECTIVE

Laryngeal diadochokinetic (L-DDK) rate is a measure of laryngeal neural integrity. The objectives for this study included the following: (1) establish the first comprehensive pediatric normative database for L-DDK rates (DDK) using the Voice Evaluation Suite, a computerized voice analysis program; and (2) analyze normal L-DDK rates for age and gender differences.

STUDY DESIGN

Cross-sectional study with planned data collection.

SETTING

Outpatient pediatric otolaryngology clinic.

SUBJECTS AND METHODS

Three hundred seven children aged 4 to 18 with normal voices. L-DDK rates were collected during a 6-month period. Main outcome measures included age, gender, and L-DDK rates.

RESULTS

Three hundred seven children (151 girls and 156 boys) were evaluated. There was no statistically significant difference between the overall mean L-DDK rate of boys (2.69 syllables/s) compared to girls (2.55 syllables/s; P > .05). Further analysis of all individual age groups did not reveal any statistical significance between boys and girls. There was a statistically significant difference among children aged 4 to 11 compared to those 12 to 18 years old. Among boys aged 4 to 11, the mean rate was 2.49 syllables per second, whereas among 12- to 18-year-olds, the rate was 2.95 syllables per second (P < .01). The mean rate was 2.40 syllables per second among girls aged 4 to 11 and 2.74 syllables per second for those aged 12 to 18 (P < .01).

CONCLUSION

This is the largest normative pediatric L-DDK analysis in the English literature. The findings suggest that neurolaryngeal development approaches adult maturation at the beginning of the teenage years. These data have the potential application for objective measurement of neurolaryngeal coordination in children with neurologic impairment and also in children who have undergone nerve reinnervation procedures.

MRI with synchronized audio to evaluate velopharyngeal insufficiency

OBJECTIVE

To demonstrate the feasibility of simultaneous-acquired magnetic resonance imaging (MRI) and high-quality synchronized audio recording for evaluating velopharyngeal closure.

DESIGN

Institutional Review Board-approved case series.

SETTING

Tertiary care hospital.

PATIENTS

Three healthy adult volunteers with a normal speech pattern.

INTERVENTIONS

MRI with simultaneous recorded audio files evaluating velopharyngeal closure.

MAIN OUTCOME MEASURE

Precise imaging and audio coordination of specific phonatory tasks.

RESULTS

Synchronization of MRI and audio in all three adults.

CONCLUSION

Our novel imaging and audio protocol provides simultaneous acquired MRI with synchronized high quality audio for evaluating velopharyngeal closure. This technique may provide the opportunity to improve diagnosis and surgical planning in patients with velopharyngeal insufficiency.

Prevalence of noise-induced hearing-threshold shifts and hearing loss among US youths

OBJECTIVE

We investigated trends in noise-induced threshold shifts (NITSs), high-frequency hearing loss (HFHL), and low-frequency hearing loss (LFHL).

METHODS

A total of 4310 adolescents 12 to 19 years of age completed audiometric testing during National Health and Nutrition Examination Surveys in 1988-1994 and 2005-2006. NITS criteria were audiometric patterns of decreased 3- to 6-kHz thresholds but preserved 0.5- to 1-kHz and 8-kHz thresholds; HFHL and LFHL criteria were high and low pure-tone averages, respectively, of >15 dB HL.

RESULTS

There were no significant increases in NITSs (odds ratio [OR]: 0.81 [95% confidence interval [CI]: 0.53-1.22]; P = .29), HFHL (OR: 1.21 [95% CI: 0.87-1.69]; P = .25), or LFHL (OR: 1.37 [95% CI: 0.77-2.45]; P = .28) between survey periods. However, a significant increase in the prevalence of NITSs occurred among female youths (11.6% [95% CI: 9.0%-14.1%] vs 16.7% [95% CI: 13.2%-20.3%]; P < .0001). The overall prevalence of exposure to loud noise or listening to music through headphones in the previous 24 hours increased from 19.8% (95% CI: 17.6%-22.1%) to 34.8% (95% CI: 31.0%-38.5%; P < .0001). In 2005-2006, female youths had a similar prevalence of exposure to recreational noise (23.6% [95% CI: 19.6%-27.6%] vs 27.7% [95% CI: 23.6%-31.8%]; P < .0001) and a lower prevalence of hearing-protection use (3.4% [95% CI: 1.6%-5.3%] vs 10.3% [95% CI: 7.3%-13.2%]; P < .0001) compared with male youths.

CONCLUSIONS

Increased exposure to recreational noise and minimal use of hearing protection might have lead to an increase in NITS prevalence among female youths.

Multicenter interrater and intrarater reliability in the endoscopic evaluation of velopharyngeal insufficiency

OBJECTIVE

To explore interrater and intrarater reliability (R (inter) and R (intra), respectively) of a standardized scale applied to nasoendoscopic assessment of velopharyngeal (VP) function, across multiple centers.

DESIGN

Multicenter blinded R (inter) and R (intra) study.

SETTING

Eight academic tertiary care centers.

PARTICIPANTS

Sixteen otolaryngologists from 8 centers.

MAIN OUTCOME MEASURES

Raters estimated lateral pharyngeal and palatal movement on nasoendoscopic tapes from 50 different patients. Raters were asked to (1) estimate gap size during phonation and (2) note the presence of the Passavant ridge, a midline palatal notch on the nasal surface of the soft palate, and aberrant pulsations. Primary outcome measures were R (inter) and R (intra) coefficients for estimated gap size, lateral wall, and palatal movement; kappa coefficients for the Passavant ridge, a midline palatal notch on the nasal soft palate, and aberrant pulsations were also calculated.

RESULTS

The R (inter) coefficients were 0.63 for estimated gap size, 0.41 for lateral wall movement, and 0.43 for palate movement; corresponding R (intra) coefficients were 0.86, 0.79, and 0.83, respectively. Interrater kappa values for qualitative features were 0.10 for the Passavant ridge; 0.48 for a notch on the nasal surface of the soft palate, 0.56 for aberrant pulsations, and 0.39 for estimation of gap size.

CONCLUSIONS

In these data, there was good R (intra) and fair R (inter) when using the Golding-Kushner scale for rating VP function based on nasoendoscopy. Estimates of VP gap size demonstrate higher reliability coefficients than total lateral wall, mean palate estimates, and categorical estimate of gap size. The reliability of rating qualitative characteristics (ie, the presence of the Passavant ridge, aberrant pulsations, and notch on the nasal surface of the soft palate) is variable.