Laryngeal Cleft Repair Research Articles

Pediatric Robotic Laryngeal Cleft Repair.

Compare surgical and swallow outcomes in robotic versus traditional laryngeal cleft (LC) repairs. Retrospective cohort study. Tertiary care pediatric hospital. Pediatric patients who underwent robotic or traditional (open or endoscopic) LC repair between 2010 and 2021 were identified. Patient characteristics, operative times, adverse events, hospital length of stay (LOS), and modified barium swallow study (MBSS) results were compared. Eighteen robotic and thirty traditional LC repairs were identified. Mean surgical (149 vs 111 min, P < .05) and OR times (207 vs 139 min, P < .002) were increased for robotic type I LC repairs, but were similar for type II and III LC. Mean hospital LOSwas increased for robotic type I LC repairs (2.6 vs 1.2 days, P < .006), but was decreased for type II (4 vs 12.2 days) and type III (4.3 vs 94.5 days) LC. Postoperative MBSS results were improved for robotic type I LC repairs at 12 months (82% vs 43%, P = .05), and trended towardimprovement at 6 months for type II (75% vs 22%), and type III (67% vs 50%) LC repairs, although significance was limited for type II and III LC due to the number of subjects. A robotic approach was used successfully to revise all recurrent LC that failed traditional repairs. Robotic type 1 LC repairs demonstrated increased operative times and hospital LOS but improved postoperative swallow outcomes compared to traditional approaches maybe particularly useful in cases of recurrent clefts.

Long-term Airway Outcomes and Interventions in Children With Oesophageal Atresia With Tracheoesophageal Fistula: A 20-year Single Centre Observational Study

BackgroundAirway anomalies, symptoms and interventions are commonly reported in children with oesophageal atresia with tracheoesophageal fistula (OA/TOF). The purpose of this study was to assess the incidence of these airway pathologies and those requiring interventions in the long-term. MethodsA retrospective case note review of all patients admitted to the Neonatal Unit at the Royal Hospital for Children, Glasgow between January 2000 and December 2015 diagnosed with OA/TOF. Included patients had a minimum of 5 years follow-up. Results121 patients were identified. 118 proceeded to OA/TOF repair. 115 patients had long-term follow-up data. Ninety-five (83%) children had one or more airway symptom recorded. Thirty-six (31%) neonates underwent airway endoscopy at the time of their initial OA/TOF repair. Forty-six (40%) children underwent airway endoscopy at a later date due to airway symptoms. Airway pathologies identified included airway malacia, thirty-two (28%), subglottic stenosis, eleven (10%), tracheal pouch, twenty-five (22%), laryngeal cleft, seven (6%) and recurrent fistula, five (4%). Airway interventions included endoscopic division of tracheal pouch, ten (9%), tracheostomy, seven (6%), aortopexy, six (5%), repair of recurrent fistula, five (4%), endoscopic repair of laryngeal cleft, three (3%) and four (3%) required open airway reconstruction for subglottic stenosis. One child (1%) remains tracheostomy dependent. ConclusionsLong-term airway pathologies are common in children with OA/TOF. Many of these are remediable with surgical intervention. Clinicians should be cognisant of this and refer to Airway Services appropriately.

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.

Repair of posterior laryngeal cleft: a 10-year experience in a tertiary referral hospital.

This study aimed to present experience with surgical treatment of laryngeal cleft cases through both open and endoscopic approaches. A retrospective evaluation of all patients diagnosed as having a laryngeal cleft in a tertiary hospital over 10 years was performed. Pre-operative data, conservative and surgical management of cases, and outcomes were collected, tabulated and analysed. This study included 43 patients aged from 2 to 44 months with a median of 9.19 months. Concerning management technique, 12 patients had conservative treatment and the remaining 31 underwent a surgical procedure (of them, 20 patients underwent endoscopic intervention and 11 had the open surgical technique). In the open group, we used either tibial periosteum (six cases) or harvested costal cartilage (five cases). Surgical management in the form of endoscopic Coblation-assisted or an open approach is indicated in severe cases or mild cases not responding to conservative management.

Pediatric laryngeal cleft repair with coblation: Functional comparison of a novel technique with traditional methods.

The traditional endoscopic techniques for surgical management of laryngeal clefts are carbon dioxide (CO2) laser or microlaryngeal instruments (cold steel). This study compares the functional efficacy and safety of coblation, or "cold" radiofrequency ablation, to traditional approaches for endoscopic laryngeal cleft repair. Patients who underwent endoscopic laryngeal cleft repair with CO2 laser, cold steel, or coblator at two tertiary academic centers from 2015 to 2021 were retrospectively identified. The primary outcome studied was swallowing function: pre- and postoperative swallow studies were scored according to the International Dysphagia Diet Standardization Initiative with higher scores indicating worse swallow function. Secondary outcomes included surgical complications and rates of dehiscence. Of the 53 patients included, 14 underwent repair with CO2 laser, 23 with cold steel, and 16 with the coblator. Mean age at surgery was 2.2±1.1 years for the laser group, 4.3±4.0 years for cold steel, and 1.9±1.4 years for the coblator group. In the laser group, 100% of clefts were type I; for the cold steel group, 82.6% of clefts were type I and 17.4% were type II; for the coblator group, 93.8% of clefts were type I and 6.3% were type II. Pre- and postoperative swallow study scores were 6.3±2.8 and 4.3±3.2, respectively, (p=0.001) for the laser group, 6.9±2.8 and 5.3±3.1 (p=0.071) for the cold steel group, and 7.5±1.5 and 4.0±2.9 (p<0.001) for the coblator group. Mean change in swallow study scores were similar across the three groups (p=0.212). No patients experienced postoperative dehiscence at the surgical site or complications; no revisions were required. Cleft repair with the novel coblation technique showed significant improvements in swallow study scores without any occurrences of postoperative dehiscence or revisions. Coblation is a safe and efficacious approach for laryngeal cleft repair.

674 A Rare Cause of Dysphagia in an Adult: Laryngeal Cleft, a Case Report from a Tertiary Care Centre

Abstract Introduction Laryngeal cleft is a rare congenital anomaly where the laryngotracheal wall fails to fuse posteriorly resulting in a gap. Embryologically, larynx develops from IV and VI branchial arches and is separated from foregut by trachea-esophageal septum, which closes from caudal to cranial end. Symptoms can vary, depending on where these fusion arrests, from none in mild cases to aspiration, recurrent pneumonia, dysphagia, and hoarseness of voice in severe. The condition is almost always detected in childhood and rarely diagnosed in adults. Method We present a case of 41-year-old male with dysphagia and choking episodes, having previously been treated for cleft palate and larynx as a child alongside a literature review of such published cases. Results A 41-year-old male developed swallowing problems with choking episodes on a background of having had a successful repair of a type 3 cleft in childhood. He underwent video fluoroscopy which demonstrated evidence of aspiration. He subsequently underwent a diagnostic microlaryngoscopy, which disclosed a type III laryngeal cleft. He was treated surgically with open laryngeal cleft repair, following which the postoperative fibreoptic endoscopic evaluation of swallowing demonstrated strong swallow. He was discharged home on successful resumption of his baseline diet. Conclusion Laryngeal clefts in adults are very rare and can be successfully treated surgically. The case report showcases the condition can still present in adult life with late failure (breakdown) and the need for awareness about the disorder. A review revealed very few reported adult cases in the current literature.

A Validated 3D Printed Laryngeal Suturing Simulator for Endoscopic Laryngeal Cleft Repair.

Endoscopic laryngeal cleft repair (ELCR) with endolaryngeal suturing is an advanced surgical skill. This study objective was to assess the validity of 3-dimensionally (3D) printed laryngeal suturing simulator for ELCR. Development and validation of a simulator for ELCR. An ELCR model was developed using 3D printed and readily available materials. Participants were surveyed before and after a simulation session using five-point Likert scale questions. Performance data was assessed using blinded expert video review and rated using a novel objective structured assessment of technical skills (OSATS) for endoscopic laryngeal suturing. Twenty-one participants ranging from residents to attendings completed the simulation session. Survey respondents reported on a five-point Likert scale that the model was "easy to use" and "quite realistic" (both mean of 4). Confidence improved significantly in 86% of participants (p < 0.01). Overall OSATS scores (out of a total of 55) showed a median improvement in technical skills of 11.7 points (p=0.004). OSATS demonstrated good intra-rater (κ=0.689 and 0.677) and moderate inter-rater (κ=0.573) reliability. Completion times improved from the first to the last suture by a median time of 512 to 350 s (decrease of 202 s, p=0.002). Participants with no prior ELCR experience improved more than those with in vivo experience. This study demonstrates the validity of a simulator utilizing 3D printed larynges for ELCR. A novel OSATS for endoscopic laryngeal suturing was successfully implemented. Confidence, technical skills, and completion times improved with the use of the model across a variety of participants. Laryngoscope, 133:785-791, 2023.

Postoperative respiratory adverse events in children after endoscopic laryngeal cleft repair

Due to the serious nature of respiratory adverse events, understanding their incidence can help in decisions regarding safe postoperative disposition. There have been no studies, however, evaluating the risk of postoperative respiratory adverse events (PRAEs) in children undergoing endoscopic laryngeal cleft (LC) repair, which is the primary objective of this study. We conducted a retrospective chart review of all patients who underwent LC repair at a large tertiary children's hospital from 2015 to 2020. PRAEs were defined as having at least one of the following: remained intubated, required reintubation, required positive pressure ventilation, required high flow O2 nasal cannula, or required more than one dose of racemic epinephrine. Univariate analyses compared demographic, preoperative characteristics, and intraoperative characteristics between those with and without a PRAE. Overall, 8/26 (31%) patients had a PRAE and there were no differences between patients who did and did not have a PRAE and most comorbidities. Younger age (p = 0.03), being male (p = 0.07), and being admitted preoperatively (p = 0.07) were potentially associated with PRAEs. Need for intraoperative intubation for any reason or duration was associated with increased incidence of PRAEs (p = 0.02). The overall 31% incidence of postoperative respiratory adverse events reaffirms the appropriateness of PICU disposition for a large proportion of children undergoing endoscopic LC repair. Further studies with increased sample sizes are needed to tease apart patient or procedure-specific factors that significantly increase the risk of respiratory adverse events to have more definitive evidence regarding safe postoperative disposition.

A Case Study Vignette for a Pediatric Patient With Eosinophilic Esophagitis

ObjectivesEosinophilic Esophagitis (EoE) is a chronic inflammatory, immune/antigen-mediated condition of the esophagus. It is common in pediatric patients and can lead to several complications such as esophageal remodeling/fibrosis, growth stunting, and low bone mineral density. Nutrition interventions, such as elimination or elemental diets, are the first therapeutic tool for EoE management along with pharmacological interventions. MethodsKS is a 20 month-old female whose weight-for-length has fallen above the 55th percentile since birth. She has a history of gastroesophageal reflux, dysphagia, and aspiration requiring thickened liquids for almost 2 years. During infancy she tolerated milk based thickened formula and transitioned to 1% milk at 1 year. She was diagnosed with EoE during a triple endoscope for laryngeal cleft repair. The pathology revealed rings and furrows in the mid/distal esophagus, and > 20 eosinophils per high powered field (HPF) in distal, mid, and proximal esophagus with evidence of subepithelial fibrosis. At that time she had no dietary restrictions or use of antacids. Since cleft repair, dysphagia improved and she started on a dairy free diet for EoE. However, she experienced an adverse reaction to dairy free nut-based cheese with subsequent positive radioallergosorbent testing to tree nuts. Follow-up endoscopy improved on an 8-week dairy and tree nut free diet, but eosinophils persisted in proximal esophagus with evidence of basal cell hyperplasia. ResultsThe patient was able to make important strides towards remission by eliminating suspected trigger foods, with diagnosis and intervention initiation before signs of inadequate growth or nutrition. ConclusionsNutrition interventions are often imperative to achieve remission of EoE. There are potential nutrition related concerns including increased risk of nutrient deficiencies, inadequate growth, and poor quality of life as the patient follows an elimination/elemental diet. EoE should become a consideration when feeding or swallowing difficulties arise, especially in pediatric patients. Proper diagnosis, tailored interventions, and appropriate monitoring and evaluation with the help of a multidisciplinary team can lead to successful management. Funding SourcesN/A.

Endoscopic Repair of Laryngeal Clefts: 8 Years' Experience.

To emphasize the need for high clinical suspicion in the diagnosis of Laryngeal cleft in paediatric population, to catalogue the pattern of presentation, time to treatment and the evolution of surgical techniques for Laryngeal cleft repair at our center. A retrospective review of laryngeal cleft cases which presented over a period of 8years (May 2012-May 2020), from a tertiary care center, was done. Data includes-patient demographics, preliminary investigations, diagnostic methods, type of cleft, surgical steps and post-operative follow up. Extensive literature search was done and we could not find similar studies from South East Asia and the Indian subcontinents. Of the 10 patients 7 were managed surgically and 3 conservatively. There was an equal distribution of type 1 (n = 5) and 2 (n = 5) clefts. 80% cases were males and 9 out of 10 patients had associated congenital anomalies. 80% cases had symptom resolution (75% were managed surgically and 25% managed medically). Surgical intervention should be based on the extent of anatomical defect and the functional impairment caused by cleft such as respiratory problems, persistence of feeding issues despite maximal medical management and feeding therapy. Early surgical management of type I and II clefts have satisfactory outcomes.

Postoperative dysphagia immediately following pediatric endoscopic laryngeal cleft repair

ObjectivesIn pediatric patients undergoing endoscopic laryngeal cleft repair, immediate postoperative dysphagia is not well-characterized. This study examined whether worsened dysphagia is present in the immediate postoperative period as detected by clinical swallow evaluation, and evaluated how this relates to postoperative change in presenting symptoms and findings on swallow studies. MethodsA retrospective cohort was conducted at a tertiary academic medical center, evaluating all pediatric patients who underwent endoscopic laryngeal cleft repair by a single surgeon from October 2014 through December 2018. All patients underwent instrumental swallow evaluation preoperatively and clinical swallow evaluation within 24 h following surgery. ResultsThirty-nine patients met inclusion criteria. Based on clinical swallow evaluation performed within 24 h after surgery, 4 patients (10%) were recommended to thicken their diet from preoperative baseline; all others were unchanged. All patients were admitted to the PICU for observation; 34 (87%) discharged on postoperative day 1. Thirty-seven patients attended 6-week follow-up, with 2 (5%) requiring thicker diet since discharge; all others were stable or improved. Prevalence of recurrent respiratory infections, subjective dysphagia, chronic cough, and wheezing significantly decreased after surgery. No statistically significant change occurred in prevalence of aspiration or penetration on instrumental swallow studies postoperatively. ConclusionEndoscopic laryngeal cleft repair is well-tolerated in pediatric patients, and most do not have obviously worsened dysphagia at immediate postoperative evaluation. Improvement in symptoms postoperatively may be a more useful indicator of surgical outcomes beyond instrumental swallow studies alone. The relative stability of these patients provides further evidence that they can likely be managed on the floor or as outpatients rather than in the ICU postoperatively.

Pediatric airway surgery under spontaneous respiration using high-flow nasal oxygen

ObjectivesIn pediatric airway surgery, SponTaneous Respiration using IntraVEnous anesthesia and Hi-flow nasal oxygen (STRIVE Hi) has not been well explored. Here, we report our experience of using STRIVE Hi in endoscopic evaluations and surgeries of the pediatric airway. MethodsThis retrospective review was based on 45 airway procedures conducted under STRIVE Hi, performed by a single surgeon at a single institute from May 2017 to September 2018. After induction of anesthesia, continuous infusion with propofol and remifentanil was provided to ensure an adequate level of anesthesia and supply of humidified oxygen via a nasal cannula. Monitoring was conducted using a transcutaneous CO2 sensor and a pulse oximeter, and the oxygen reserve and bispectral indexes were measured. No muscle relaxant was administered. ResultsThe median age of the patients was 16.0 months (range: 1–215 months) and the median weight was 10.2 kg (range: 2.4–38.5 kg). The median duration of spontaneous respiration was min 40 (range: 10–140 min). The airway procedures included diagnostic microlaryngoscopy, tracheocutaneous fistula excision, balloon dilation, supraglottoplasty, laryngeal cleft repair, injection laryngoplasty, papilloma excision, and subglottic cyst removal. During these procedures, STRIVE Hi facilitated evaluation of dynamic obstruction of the airway and the immediate outcome of surgical treatment and provided a good surgical view. Intubation and the termination of spontaneous respiration were required in only five patients. ConclusionsSTRIVE Hi is an effective and feasible anesthesia option in pediatric airway surgery. It provides unobstructed surgical access and is applicable to a wide range of procedures.

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

ObjectiveIdentify incidence and factors associated with respiratory complications after type 1 cleft repair. MethodsRetrospective chart review of patients who underwent cleft repair over a 5-year period performed by a single surgeon. Primary endpoint was respiratory complications (oxygen desaturation <90%). Fisher's exact test was used to identify differences between repair types (endoscopic carbon dioxide laser-assisted repair and injection laryngoplasty). Logistic regression was used to identify predictors of respiratory events. ResultsFifty-five patients were included. Thirty-four (62%) patients underwent endoscopic carbon dioxide laser-assisted repair and 21 (38%) underwent injection laryngoplasty. Average hospital stay for each group was 1.6 days (SD = 3.1) and 0.6 days (SD = 0.9), respectively. Desaturations occurred in three patients (9%) in the laser-assisted repair group and one patient (4%) in the injection group. All occurred within 3 h after surgery and resolved with supplemental oxygen, oral airway placement, and/or mask ventilation. Two affected patients had comorbid diagnosis of asthma (one had poor medication compliance), and one had a history of developmental delay and hypotonia. In the injection group, desaturations occurred in one patient with a history of tracheal stenosis and double aortic arch. No correlation existed between repair type and desaturation (p = 0.57). No variables were significant predictors of events. ConclusionsIn this cohort, respiratory events after type 1 laryngeal cleft repair occurred early in the postoperative period, in children with cardiac and pulmonary comorbidities. This suggests postoperative admission may only be necessary for a select group of patients undergoing type 1 cleft repair. However, further research is needed to determine criteria for same-day discharge.

Implementing a Pediatric Perioperative Surgical Home Integrated Care Coordination Pathway for Laryngeal Cleft Repair.

The Pediatric Perioperative Surgical Home (PPSH) model is an integrative care model designed to provide better patient care and value by shifting focus from the patient encounter level to the overarching surgical episode of care. So far, no PPSH model has targeted a complex airway disorder. It was hypothesized that the development of a PPSH for laryngeal cleft repair would reduce the high rates of postoperative resource utilization observed in this population. Institutional review board approval was obtained for the purpose of data collection and analysis. A multidisciplinary team of anesthesiologists, surgeons, nursing staff, information technology specialists, and finance administrators was gathered during the PPSH development phase. Standardized perioperative (preoperative, intraoperative, and postoperative) protocols were developed, with a focus on preoperative risk stratification. Patients presenting before surgery with ≥1 predefined medical comorbidity were triaged to the intensive care unit (ICU) postoperatively, while patients without severe systemic disease were triaged to a lower-acuity floor for overnight observation. The success of the PPSH protocol was defined by quality outcome and value measurements. The PPSH initiative included 120 patients, and the pre-PPSH period included 115 patients who underwent laryngeal cleft repair before implementation of the new process. Patients in the pre-PPSH period were reviewed and classified as ICU candidates or lower acuity floor candidates had they presented in the post-PPSH period. Among the 79 patients in the pre-PPSH period who were identified as candidates for the lower-acuity floor transfer, 70 patients (89%) were transferred to the ICU (P < .001). Retrospective analysis concluded that 143 ICU bedded days could have been avoided in the pre-PPSH group by using PPSH risk stratification. Surgery duration (P = .034) and hospital length of stay (P = .015) were found to be slightly longer in the group of pre-PPSH observation unit candidates. Rates of 30-day unplanned readmissions to the hospital were not associated with the new PPSH initiative (P = .093). No patients in either group experienced emergent postoperative intubation or other expected complications. Total hospital costs were not lower for PPSH observation unit patients as compared to pre-PPSH observation unit candidates (difference = 8%; 95% confidence interval, -7% to 23%). A well-defined preoperative screening protocol for patients undergoing laryngeal cleft repair can reduce postoperative ICU utilization without affecting patient safety. Further research is needed to see if these findings are applicable to other complex airway surgeries.

Influence of preoperative voice assessment on treatment plan prior to airway surgery.

Voice quality has emerged as an additional long-term outcome measure for patients with a history of airway surgery. The goal of this study was to evaluate the impact of preoperative voice assessment on the surgical management of patients who required complex airway surgery. Retrospective case series. We analyzed clinical data for all patients who underwent an airway reconstruction procedure from September 1, 2012 to September 1, 2017 and had a voice clinic evaluation prior to surgery at a tertiary-care pediatric hospital. Each participant underwent a full clinical voice evaluation that yielded acoustic, imaging, perceptual, and handicapping index data. Six hundred forty-three patients underwent 831 airway surgeries (laryngotracheoplasty, cricotracheal resection, slide tracheoplasty, laryngeal cleft repair). Ninety-one (14.2%) of the 643 patients underwent a formal voice clinic evaluation prior to airway surgery; 39/91 (42.9%) were female. The mean age was 10.4 years (95% confidence interval [CI]: 9.2-11.6) with 31/91 (32.9%) participants demonstrating vocal fold immobility and 33/91 (36.3%) vocal fold hypomobility. A voice clinic evaluation provided new information for 62/91 (68.1%) patients, mainly for laryngeal dynamic components (vocal fold motion, source of phonation, arytenoid prolapse) and confirmed suspected disorders for the remaining patients. The average baseline Pediatric Voice Handicap Index overall score was 38.9 (95% CI: 33.3-44.5), and the average overall severity rating of the Consensus Auditory-Perceptual Evaluation of Voice was 54 (95% CI: 45.2-62.8). A voice clinic evaluation influenced management of 56/91 (61.5%) patients either by modification of the surgical plan (26/56, 46%) and/or adjusting voice therapy (21/56, 37.5%). Voice evaluation prior to airway reconstruction provided key information that influenced the management for most of the patients. Formal voice evaluation should be considered prior to complex airway surgery. 4 Laryngoscope, 128:2858-2863, 2018.

Pediatric laryngeal cleft repair and dysphagia

ObjectiveTo describe changes in diet and swallow function in patients with a laryngeal cleft after surgical repair of the laryngeal cleft. MethodsRetrospective case series performed using chart review. Primary outcomes were diet and swallow function before and after laryngeal cleft repair. Clinical evaluation and video fluoroscopic swallow studies (VFSS) were used to assess pre- and post intervention swallowing. Results16 pediatric patients were included in this study. Preoperatively, 14 (88%) patients had diet restrictions. Postoperatively, 12 (75%) patients tolerated a regular diet without limitation. 4 (25%) patients had no reduction in diet restrictions over the course of this study. For the 10 patients who transitioned to a regular diet postoperatively, a median of 300 days (range: 26 days - 3 years) passed to document achieving a regular diet. This was corroborated by an increase in normal oral and pharyngeal phase swallow function on VFSS postoperatively when compared with preoperative VFSS results. ConclusionDysphagia improves in most patients after laryngeal cleft repair. The range in time to a normal diet was wide. This may facilitate improved preoperative counseling and preparation of families' expectations.

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

ObjectiveWhereas the literature is replete with reports on complex children with dysphagia (DP), the parameters characterizing non-neurologically impaired (NNI) children have been underreported, leaving a substantial knowledge gap. We set to characterize a consecutive cohort of NNI children, their management, and outcomes. MethodsWe undertook a retrospective case series. Children (<18 years old) attending a tertiary multidisciplinary swallowing clinic were eligible. Patients with neuro-developmental, neuromuscular, or syndromic abnormalities were excluded. Primary outcomes included demographics, co-morbidities, presentations, McGill score, swallowing and airway abnormalities (and their predictors). Secondary outcomes were interventions and management response. ResultsFrom 171 consecutive patients (37-month period), 128 were included (69 males, median age 6.6 months (0.5–124.2)). Significant clinical presentations included recurrent pneumonias (20), cyanotic spells (14) and life-threatening events (10). Swallowing assessments revealed laryngeal penetration (67), aspiration (25). Other investigations included overnight oximetry (77), airway (70), and gastrointestinal endoscopy (24); revealing laryngomalacia (29), laryngeal mobility disorder (8), and subglottic stenosis (8). Non-surgical interventions involved oral diet modifications (85) and enteral nutrition (15). Surgical interventions included supraglottoplasties (18), endoscopic laryngeal cleft repair (14), and injection (19). 119 patients received intervention and at last follow-up (median 5.2 months (0.3–88.8)) 94 had improved. Of those treated 116 were on an unmodified oral diet, and 24 on a modified diet. ALTE and snoring predicted airway abnormalities, recurrent pneumonia predicted swallowing abnormalities, and age and airway lesions predicted the McGill score. Conclusiona significant proportion of NNI children with DP harbor airway and swallowing abnormalities warranting endoscopic and instrumental assessment.

The efficacy and safety of the flexible fiber CO2 laser delivery system in the endoscopic management of pediatric airway problems: Our long term experience

ObjectiveTo report the use of flexible fiber CO2 laser in the endoscopic management of pediatric airway cases. MethodsA retrospective review was conducted of patients who underwent CO2 laser-assisted airway procedures between September 2007 and January 2014 at a tertiary pediatric hospital. ResultsSixty-eight patients underwent 80 procedures utilizing flexible fiber CO2 laser. Procedures included supraglottoplasty (n = 32), laryngeal cleft repair (type I [n = 10], type II [n = 7], type III [n = 6]), suprastomal granuloma excision (n = 6), cordotomy (n = 4), laryngeal neurofibroma excision (n = 4), laryngeal granulomatous mass excision (n = 1), subglottic stenosis excision (n = 6), division of glottic web (n = 2), subglottic cyst excision (n = 1), and supraglottic biopsy (n = 1). Ages ranged from 8 days to 21 years (median 11 months). No intraoperative or postoperative complications related to the use of laser were noted. ConclusionsThe flexible fiber CO2 laser can be safely and effectively used to address a variety of pediatric airway lesions. Previously, the use of CO2 laser in minimally invasive airway surgery has been limited due to the articulating arm carrier, absence of a hand piece, and the direct line-of sight view required. The fiber allows the cutting beam to be directed at the site of the lesion and bypasses limitations posed by other laser systems.

Early surgical intervention in type I laryngeal cleft

ObjectiveDiagnosis and treatment of type 1 laryngeal clefts remains a challenge. The purpose of this study is to determine if early surgical intervention in type I laryngeal clefts improves outcomes. MethodsA retrospective case series was conducted at an academic tertiary care children's hospital. 18 children undergoing early (≤3 months from diagnosis) surgical intervention for type I laryngeal cleft repair between August of 2012 and December 2014. Data was compiled through a manual chart review. Results18 children who underwent early surgical intervention for type I laryngeal cleft repair were identified for review. 14 (78%) were male and 4 (22%) were female and the average age at time of repair was 1.6 years. Most frequent presenting symptoms included dysphagia (61%) and recurrent respiratory issues (22%). Successful swallowing outcomes, defined as subjective improvement (i.e. absence of previous symptoms) per parental report in follow-up visits, +/− normal post-operative MBS (modified barium swallow) findings, was seen in 11 patients (61%). 9 patients required hospitalization for respiratory issues prior to surgical repair. Post-operatively, 4 patients still incurred an admission for respiratory reasons. ConclusionsOur series shows a success rate of 61% with early surgical intervention (≤3 months from diagnosis). A decrease in post-operative hospitalizations is appreciated.

Modified Best-Practice Algorithm to Reduce the Number of Postoperative Videofluoroscopic Swallow Studies in Patients With Type 1 Laryngeal Cleft Repair.

There is no consensus as to the timing of videofluoroscopic swallow studies (VFSSs) in determining resolving aspiration after laryngeal cleft repair. There is a growing literature on the effect of radiation exposure in children. To modify a previously published best-practice algorithm based on a literature review and our clinical experience to maintain the quality of care provided after successful type 1 laryngeal cleft repair, while reducing the total number of postoperative VFSSs by 10% or greater. The previously published algorithm was modified by a multidisciplinary group at a tertiary care academic medical center (Massachusetts Eye and Ear) and was prospectively applied to 31 children who underwent type 1 laryngeal cleft repair from January 1, 2013, to February 28, 2015. The number of VFSSs obtained in the first 7 months after surgery was compared with the peer-reviewed literature and with a retrospective cohort of 27 patients who underwent type 1 laryngeal cleft repair from January 1, 2008, to December 31, 2012. The study cohort comprised 31 patients. Their ages ranged from 10 to 48 months, with a mean (SD) age of 23.94 (9.93) months, and 19% (6 of 31) were female. The mean (SD) number of postoperative VFSSs per patient before and after implementation of the algorithm was 1.22 (0.42) and 1.03 (0.55), respectively. The use of the algorithm reduced the number of VFSSs by 0.19 (95% CI, -0.07 to 0.45). This reduction in radiation exposure is equivalent to 1.47 chest radiographs per child per course of care. Surgical success was 87% (27 of 31) compared with our group's previously published success rate of 78% (21 of 27) (absolute difference, 0.09; 95% CI, -0.17 to 0.34). This modified algorithm to help guide decisions on when and how often to obtain VFSSs after type 1 laryngeal cleft repair can limit patients' radiation exposure, while maintaining high surgical success rates.