Publications by authors named "Karen B Zur"

54 Publications

Tracheostomy on infants born in the periviable period: Outcomes at discharge from the neonatal intensive care unit (NICU).

Int J Pediatr Otorhinolaryngol 2021 Jul 27;146:110746. Epub 2021 Apr 27.

Department of Otorhinolaryngology H & N Surgery, University of Maryland School of Medicine and University of Maryland Children's Hospital, Baltimore, MD, USA.

Objectives: Advances in neonatal intensive care have allowed successful resuscitation of children born at the border of viability. However, there has been little change in the incidence of bronchopulmonary dysplasia (BPD) and anatomical upper airway obstruction which may require a tracheostomy in that group. The benefits of the procedure are accompanied by sequelae that impact outcomes. Information about these issues can assist caregivers in making decisions and planning care after discharge from the neonatal intensive care unit (NICU). The objectives of this study were to describe the clinical characteristics of neonates born in the periviable period (≤25 weeks gestation) requiring tracheotomy and to highlight their hospital course, complications and status upon NICU discharge.

Methods: Retrospective analysis at four tertiary care academic children's hospitals. Medical records of neonates born ≤25 weeks gestation who required tracheotomy between January 1, 2012 and December 31, 2018 were reviewed. Demographics, medical comorbidities, and tracheostomy related complications were studied. Feeding, ventilation, and neurodevelopmental outcomes at time of transfer from NICU were evaluated.

Results: Fifty-two patients were included. The mean gestational age was 24.3 (95% confidence interval, 24.1 to 24.5) weeks. The mean birth weight was 635 (95% CI: 603 to 667) grams and 50 (96.2%) children had BPD. At time of discharge from the NICU, 47 (90.4%) required mechanical ventilation, four (7.7%) required supplemental oxygen and one (1.9%) was weaned to room air. Forty-two (80.8%) were discharged with a gastrostomy tube, seven (28%) with a nasogastric tube, and three (5.8%) were on oral feeds. Two (3.8%) suffered hypoxic ischemic encephalopathy, 27 (51.9%) had neurodevelopmental delay, seven (13.5%) were diagnosed with another anomaly, and 16 (30.8%) were considered normal. Complications related to the procedure were observed in 28 (53.8%) neonates. Granulation tissue was seen in 17 (32.7%), wound break down or cellulitis in three (5.8%), one (1.9%) with tracheostomy plugging, three (5.8%) with dislodgement of the tracheostomy tube and four (7.7%) developed tracheitis.

Conclusions: Tracheostomy in infants born in the periviable period is primarily performed for BPD and portends extended ventilatory dependence. It is associated with non-oral alimentation at the time of discharge from the NICU and developmental delay. Mortality directly related to the procedure is rare. Minor complications are common but do not require surgical intervention. These data may aid in counseling caregivers about the procedure in this vulnerable population.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijporl.2021.110746DOI Listing
July 2021

Intubation-Related Laryngeal Deficiency and Vocal Fold Immobility in Pediatric Premature Patients.

Laryngoscope 2021 May 6. Epub 2021 May 6.

Division of Pediatric Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A.

Objectives/hypothesis: We report a posterior laryngeal rating system and measures of voice disability in pediatric patients undergoing phonosurgery for vocal fold paralysis. Posterior glottic deficiency may account for persistent voice disability.

Study Design: Retrospective Study.

Methods: Retrospective analyses of 66 subjects with primary unilateral vocal fold paralysis were reviewed for the status of posterior glottis and voice disability (Pediatric Voice Handicap Index [pVHI]). Gestation age (GA), weight, and medical/surgical history were reviewed. The width, length, and depth of the larynx were analyzed to create a reproducible rating scale.

Results: Mean GA was 29 weeks, with an intubation history for all subjects, with 90% having a left vocal fold immobility. Cardiac surgery was performed in 92% of subjects. A progressive rating (type 0-3) Benjamin Defect Severity Scale (BDSS) was developed to rate the absence or presence of a posterior abnormality. BDSS-2 and BDSS-3 subjects were more likely to have low birth weight. Extremely preterm GA was more likely to be associated with BDSS-1 (mild) or BDSS-2. History of multiple and prolonged intubations were seen more frequently in BDSS-2 or BDSS-3. Post-op pVHI reduced an average of 15 points for BDSS-0 to BDSS-2, but only 3 points for BDSS-3. Post-op pVHI matched normal values for preintervention dysphonic children.

Conclusions: The presence of a persistent breathy voice after intervention for unilateral vocal fold immobility is potentially associated with posterior glottic defects. Low birth weight with multiple/prolonged intubation is more likely to be present with higher-grade BDs, whereas low GA is more likely to be associated with BDSS-1 to BDSS-2.

Level Of Evidence: 4 Laryngoscope, 2021.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/lary.29592DOI Listing
May 2021

Drug delivery to the pediatric upper airway.

Adv Drug Deliv Rev 2021 Jul 1;174:168-189. Epub 2021 May 1.

Department of Surgery, Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA; Department of Bioengineering, School of Engineering and Applied Science, University of Pennsylvania, Philadelphia, PA 19104, USA; Department of Pediatrics, Division of Pulmonary Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA; Ri.MED Foundation, Palermo, PA 90133, Italy. Electronic address:

Pediatric upper airway disorders are frequently life-threatening and require precise assessment and intervention. Targeting these pathologies remains a challenge for clinicians due to the high complexity of pediatric upper airway anatomy and numerous potential etiologies; the most common treatments include systemic delivery of high dose steroids and antibiotics or complex and invasive surgeries. Furthermore, the majority of innovative airway management technologies are only designed and tested for adults, limiting their widespread implementation in the pediatric population. Here, we provide a comprehensive review of the most recent challenges of managing common pediatric upper airway disorders, describe the limitations of current clinical treatments, and elaborate on how to circumvent those limitations via local controlled drug delivery. Furthermore, we propose future advancements in the field of drug-eluting technologies to improve pediatric upper airway management outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.addr.2021.04.004DOI Listing
July 2021

Tracheocutaneous Fistula After Pediatric Open Airway Reconstruction.

Ann Otol Rhinol Laryngol 2021 Jan 8:3489420987426. Epub 2021 Jan 8.

Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.

Objectives: Tracheocutaneous fistula (TCF) is a common occurrence after pediatric tracheostomy decannulation. However, the persistence of TCF after staged reconstruction of the pediatric airway is not well-described. The primary objective was to determine the rate of persistent TCF after successful decannulation in children with staged open airway reconstruction.

Methods: A case series with chart review of children who underwent decannulation after double-stage laryngotracheal reconstruction between 2017 and 2019.

Results: A total of 26 children were included. The most common open airway procedure was anterior and posterior costal cartilage grafting (84.6%, 22/26). Median age at decannulation was 3.4 years (IQR: 2.8-4.3) and occurred 7.0 months (IQR: 4.3-10.4) after airway reconstruction. TCF persisted in 84.6% (22/26) of children while 15.4% (4/26) of stomas closed spontaneously. All closures were identified by the one-month follow-up visit. There was no difference in age at tracheostomy ( = .86), age at decannulation ( = .97), duration of tracheostomy ( = .43), or gestational age ( = .23) between stomas that persisted or closed. Median diameter of stent used at reconstruction was larger in TCFs that persisted (7.0 mm vs 6.5 mm,  = .03). Tracheostomy tube diameter ( = .02) and stent size ( < .01) correlated with persistence of TCF on multivariable logistic regression analysis. There were 16 surgical closure procedures, which occurred at a median of 14.4 months (IQR: 11.4-15.4) after decannulation. Techniques included 56.3% (9/16) by primary closure, 18.8% (3/16) by secondary intention and 25% (4/16) by cartilage tracheoplasty. The overall success of closure was 93.8% (15/16) at latest follow-up.

Conclusions: Persistent TCF occurs in 85% of children who are successfully decannulated after staged open airway reconstruction. Spontaneous closure could be identified by 1 month after decannulation and was more likely when smaller stents and tracheostomy tubes were utilized. Surgeons should counsel families on the frequency of TCF and the potential for additional procedures needed for closure.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/0003489420987426DOI Listing
January 2021

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

Int J Pediatr Otorhinolaryngol 2021 Feb 15;141:110565. Epub 2020 Dec 15.

Division of Otolaryngology, Children's National Medical Center, George Washington University, Washington DC, USA.

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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijporl.2020.110565DOI Listing
February 2021

International Pediatric Otolaryngology Group (IPOG) consensus recommendations: Management of suprastomal collapse in the pediatric population.

Int J Pediatr Otorhinolaryngol 2020 Dec 13;139:110427. Epub 2020 Oct 13.

Section of Pediatric ORL, Department of ORL, University Hospital Center S. Joao, University of Porto Faculty of Medicine and CINTESIS, Porto, Portugal.

Introduction: Suprastomal Collapse (SuStCo) is a common complication of prolonged tracheostomy in children. There is a paucity of literature on this subject, especially regarding how to manage significant suprastomal collapse that prevents safe decannulation.

Objective: Provide a definition, classification system, and recommend management options for significant suprastomal collapse in children with tracheostomy.

Methods: Members of the International Pediatric Otolaryngology Group (IPOG) who are experts in pediatric airway conditions were surveyed and results were refined using a modified Delphi method.

Results: Consensus was defined as > 70% agreement on a subject. The experts achieved consensus: CONCLUSION: This consensus statement provides recommendations for medical specialists who manage infants and children with tracheostomies with significant Suprastomal Collapse. It provides a classification system to facilitate diagnosis and treatment options for this condition.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijporl.2020.110427DOI Listing
December 2020

Competency-Based Assessment Tool for Pediatric Esophagoscopy: International Modified Delphi Consensus.

Laryngoscope 2021 05 9;131(5):1168-1174. Epub 2020 Oct 9.

Department of Otolaryngology, Head and Neck Surgery, Stanford University, Lucile Salter Packard Children's Hospital, Palo Alto, California, U.S.A.

Objectives/hypothesis: Create a competency-based assessment tool for pediatric esophagoscopy with foreign body removal.

Study Design: Blinded modified Delphi consensus process.

Setting: Tertiary care center.

Methods: A list of 25 potential items was sent via the Research Electronic Data Capture database to 66 expert surgeons who perform pediatric esophagoscopy. In the first round, items were rated as "keep" or "remove" and comments were incorporated. In the second round, experts rated the importance of each item on a seven-point Likert scale. Consensus was determined with a goal of 7 to 25 final items.

Results: The response rate was 38/64 (59.4%) in the first round and returned questionnaires were 100% complete. Experts wanted to "keep" all items and 172 comments were incorporated. Twenty-four task-specific and 7 previously-validated global rating items were distributed in the second round, and the response rate was 53/64 (82.8%) with questionnaires returned 97.5% complete. Of the task-specific items, 9 reached consensus, 7 were near consensus, and 8 did not achieve consensus. For global rating items that were previously validated, 6 reached consensus and 1 was near consensus.

Conclusions: It is possible to reach consensus about the important steps involved in rigid esophagoscopy with foreign body removal using a modified Delphi consensus technique. These items can now be considered when evaluating trainees during this procedure. This tool may allow trainees to focus on important steps of the procedure and help training programs standardize how trainees are evaluated.

Level Of Evidence: 5. Laryngoscope, 131:1168-1174, 2021.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/lary.29126DOI Listing
May 2021

Adenoidectomy Without Tonsillectomy for Pediatric Obstructive Sleep Apnea.

Otolaryngol Head Neck Surg 2021 05 22;164(5):1100-1107. Epub 2020 Sep 22.

Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.

Objective: The primary objective was to determine if obstructive sleep apnea (OSA) can improve after adenoidectomy.

Study Design: Case series with chart review.

Setting: Tertiary children's hospital between 2016 and 2018.

Methods: The study included children under 3.5 years with small (1+ or 2+) palatine tonsils, large (3+ or 4+) adenoids, and documented OSA on polysomnogram (PSG).

Results: Seventy-one children were included. Age at adenoidectomy was 2.0 years (95% CI, 1.8-2.2) and 71.8% were male. Mean follow-up was 2.5 years (95% CI, 2.3-2.7). Twenty-six children (36.6%) obtained a repeat PSG at a mean of 9.7 months (95% CI, 6.3-13.2) after adenoidectomy. Among those with a postoperative PSG, apnea-hypopnea index decreased in 77.0% (mean, -3.2 events/h; 95% CI, -14.1 to 7.6), and the proportion with moderate to severe OSA decreased from 65.4% to 30.8% ( = .03). Six children (23.1%) had a normal PSG after adenoidectomy. Tonsillectomy was performed in 14.1% of children at 12.1 months (95% CI, 7.5-16.7) after adenoidectomy. Despite similar preoperative PSG variables, younger children (1.5 vs 2.1 years, = .02) were more likely to require tonsillectomy. Substantial adenoid regrowth was identified in 1 child at the time of tonsillectomy.

Conclusion: Adenoidectomy may improve OSA in young children with large adenoids and small tonsils. However, younger age predicted the need for subsequent tonsillectomy. Prospective studies with additional PSG data are necessary to corroborate these findings.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/0194599820955172DOI Listing
May 2021

International Pediatric Otolaryngology group (IPOG) consensus on the diagnosis and management of pediatric obstructive sleep apnea (OSA).

Int J Pediatr Otorhinolaryngol 2020 Nov 5;138:110276. Epub 2020 Aug 5.

Antwerp University of Antwerp, Department of Otolaryngology Head and Neck Surgery, University of Antwerp, Antwerp, Belgium. Electronic address:

Objective: To develop an expert-based consensus of recommendations for the diagnosis and management of pediatric obstructive sleep apnea.

Methods: A two-iterative Delphi method questionnaire was used to formulate expert recommendations by the members of the International Pediatric Otolaryngology Group (IPOG).

Results: Twenty-six members completed the survey. Consensus recommendations (>90% agreement) are formulated for 15 different items related to the clinical evaluation, diagnosis, treatment, postoperative management and follow-up of children with OSA.

Conclusion: The recommendations formulated in this IPOG consensus statement may be used along with existing clinical practice guidelines to improve the quality of care and to reduce variation in care for children with OSA.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijporl.2020.110276DOI Listing
November 2020

Recorded Flexible Nasolaryngoscopy for Neonatal Vocal Cord Assessment in a Prospective Cohort.

Ann Otol Rhinol Laryngol 2021 Mar 14;130(3):292-297. Epub 2020 Aug 14.

Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.

Objective: Assessing vocal cord mobility by flexible nasolaryngoscopy (FNL) can be difficult in neonates. To date, prospective studies evaluating the incidence and diagnostic accuracy of vocal cord paralysis (VCP) after surgical patent ductus arteriosus (PDA) ligation are limited. It is unknown whether video FNL improves diagnosis in this population. This study compared video recordings with bedside evaluation for diagnosis of VCP and determined inter-rater reliability of the diagnosis of VCP in preterm infants after PDA ligation.

Methods: Prospective cohort of preterm neonates undergoing bedside FNL within two weeks of extubation following PDA ligation. In a subset, FNL was recorded. Two pediatric otolaryngologists, blinded to the initial diagnosis, reviewed the FNL video recordings.

Results: Eighty infants were enrolled and 37 with a recorded FNL were included in the cohort. Average gestational age at birth was 25.2 weeks (SD: 1.2) and postmenstrual age at FNL was 37.0 weeks (SD: 4.5), which was 9.5 days (SD: 14.7) after extubation following PDA repair. There were 6 diagnosed with left VCP (16.2%; 95% CI: 4.3-28.1%) at bedside, and 9 diagnosed by video review (24.3%; 95% CI: 10.5-38.1%) ( = .56). Videos confirmed all 6 VCP diagnosed initially, but also identified 3 additional cases. Though imperfect, reviewing FNL by video showed substantial reliability (kappa = .75), with 91.9% agreement.

Conclusion: Video recorded FNL most often confirms a bedside diagnosis of VCP, but may also identify discrepancies. Physicians should consider the limitations of diagnosis especially when infants persist with symptoms such as weak voice or signs of postoperative aspiration.

Level Of Evidence: 2b.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/0003489420950370DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7878273PMC
March 2021

Reflux as a Risk Factor for Morbidity after Pediatric Tonsillectomy: A National Cohort of Inpatients.

Laryngoscope 2021 04 18;131(4):907-910. Epub 2020 Jul 18.

Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A.

Objective: Gastroesophageal reflux (GER) has been identified as a risk factor for complications following pediatric tonsillectomy. The primary objective of this study was to examine outcomes after tonsillectomy among children with GER using a nationwide database. Secondary objectives included analyzing duration of hospitalization and total charges after admission.

Methods: A cross-sectional review of the Healthcare Cost and Utilization Project (HCUP) Kids' Inpatient Databases (KID) from 2012 and 2016.

Results: A total of 21,232 children had a tonsillectomy with or without adenoidectomy, with 1683 (7.9%) diagnosed with GER. Average age for patients with reflux was 4.4 years and for those without was 5.6 years (P < .001). The rate of primary hemorrhage was not statistically different between groups (P = .87). Patients with reflux were more likely to have respiratory complications (P = .03), aspiration pneumonitis (P < .001), and hypoxemia (P < .001) during their hospital course. Noninvasive ventilation and reintubation also occurred more frequently in this population (P < .001). Children with reflux had a longer duration of postoperative admission (3.8 vs. 2.3 days, P < .001) and higher total hospital charges ($47,129 vs. $27,584, P < .001). Multivariable regression analysis determined that reflux remained a statistically significant indicator of aspiration pneumonitis, hypoxemia, invasive and non-invasive ventilation, as well as length of admission.

Conclusion: Children with GER were significantly more likely to experience inpatient complications following tonsillectomy. Further, length of admission was higher compared to children without reflux. These results suggest that children with GER experience poorer outcomes after tonsillectomy and highlight the role for appropriate preoperative counseling and planning in this patient population. Laryngoscope, 131:907-910, 2021.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/lary.28895DOI Listing
April 2021

Algorithm-Based Pediatric Otolaryngology Management During the COVID-19 Global Pandemic: A Children's Hospital of Philadelphia Clinical Consensus.

Otolaryngol Head Neck Surg 2020 07 19;163(1):25-37. Epub 2020 May 19.

Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.

Objective: The coronavirus disease 2019 (COVID-19) pandemic requires clinicians to explore alternatives to routine patient management. Otolaryngologists caring for children commonly depend on physical examination, laboratory data, and ambulatory surgical procedures. Limiting patient care, mindful allocation of resources, and concern for safety have challenged all aspects of our health care system. This evidence-based clinical consensus is designed to guide practitioners of pediatric otolaryngology for common scenarios during this time.

Data Sources: Peer-reviewed literature, published reports, institutional guidelines, and expert consensus.

Review Methods: A clinical consensus on 6 common scenarios in pediatric otolaryngology developed with evidence-based strategies.

Conclusions: Providers should suspend all in-person nonessential office visits and elective surgical procedures. An emphasis on medical management and caregiver education will provide reasonable approaches to many of the common outpatient concerns. Surgery for chronic otitis media, obstructive sleep apnea, and acute rhinosinusitis should occur only in response to severe complications or failure of medical regimens. The approach to the pediatric neck mass focuses on timely management for oncologic etiologies and cautious surgical intervention for abscess drainage or tissue sampling. Finally, epistaxis and otorrhea must be triaged and addressed without the usual ambulatory procedures.

Implications For Practice: Adaptation of practice patterns during this unprecedented moment for our health care system requires thoughtful planning. The strategies described allow for safe handling of common pediatric otolaryngology diagnoses. Ultimately, otolaryngologists must be stewards of our global health community while advocating for the care of individual pediatric patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/0194599820923633DOI Listing
July 2020

Pediatric laryngopharyngeal reflux: Perceptual, acoustic, and laryngeal findings.

Int J Pediatr Otorhinolaryngol 2020 Jun 5;133:109974. Epub 2020 Mar 5.

Division of Otolaryngology, Children's Hospital of Philadelphia, USA; Department of Otolaryngology: Head & Neck Surgery, Perelman School of Medicine, University of Pennsylvania, USA. Electronic address:

Objectives: Describe acoustic and laryngeal findings in pediatric patients with subjective dysphonia attributed to laryngopharyngeal reflux (LPR). Determine the impact of LPR on perceived voice quality using the pediatric Voice Handicap Index (pVHI). Compare these findings with age-matched normative values as well as data on pediatric patients with dysphonia due to other etiologies.

Methods: Retrospective case series of pediatric patients (age 2-17 years) evaluated at a specialty pediatric voice clinic at a tertiary care children's hospital from January 1 2007 to December 31 2017 in whom LPR in whom LPR was deemed to be the most significant contributing factor for dysphonia based on physical examination and history. Patients with structural laryngeal abnormalities unrelated to LPR, such as raised lesions, stenosis, papillomatosis, or vocal fold immobility were excluded.

Results: 163 out of 1195 evaluable patients met inclusion criteria. Of these, 87% had pVHI and 83% had acoustic data available from their first appointment for analysis. Mean total pVHI score was 24 (range: 0-81). Perturbation measures were elevated in both females (jitter 1.38%, shimmer 4.16%) and males (jitter 2.01%, shimmer 5.62%). Laryngologic assessment revealed: vocal fold changes including erythema and/or pre-nodules in 72% of patients. Cobblestoning of any portion of the pharynx was present in 67% with hypopharyngeal cobblestoning the most common, present in 64% of patients.

Conclusion: Pediatric patients with clinically diagnosed LPR have pVHI, jitter, and shimmer scores that are comparable to previously reported patients with raised lesions, scar and immobility, and values that are significantly higher than published normative data. Dysphonic children should be assessed for LPR and treated when indicated.

Level Of Evidence: 4.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijporl.2020.109974DOI Listing
June 2020

Tracheostomy in the Extremely Premature Neonate: A Multi-Institutional Study.

Otolaryngol Head Neck Surg 2020 Apr 25;162(4):559-565. Epub 2020 Feb 25.

Department of Otorhinolaryngology-Head and Neck Surgery, University of Maryland School of Medicine and University of Maryland Children's Hospital, Baltimore, Maryland, USA.

Objective: (1) To describe characteristics associated with tracheostomy placement and (2) to describe associated in-hospital morbidity in extremely premature infants.

Study Design: Pooled retrospective analysis of charts.

Setting: Academic children's hospitals.

Subjects And Methods: The patient records of premature infants (23-28 weeks gestational age) who underwent tracheostomy between January 1, 2012, and December 31, 2017, were reviewed from 4 academic children's hospitals. Demographics, procedural morbidity, feeding, respiratory, and neurodevelopmental outcomes at the time of transfer from the neonatal intensive care unit (NICU) were obtained. The contribution of baseline characteristics to mortality, neurodevelopmental, and feeding outcomes was also assessed.

Results: The charts of 119 infants were included. The mean gestational age was 25.5 (95% confidence interval, 25.2-25.7) weeks. The mean birth weight was 712 (671-752) g. Approximately 50% was African American. The principal comorbidity was chronic lung disease (92.4%). Overall, 60.5% of the infants had at least 1 complication. At the time of transfer, most remained mechanically ventilated (94%) and dependent on a feeding tube (90%). Necrotizing enterocolitis increased the risk of feeding impairment ( = .002) and death ( = .03).

Conclusions: Tracheostomy in the extremely premature neonate is primarily performed for chronic lung disease. Complications occur frequently, with skin breakdown being the most common. Placement of a tracheostomy does not seem to mitigate the systemic morbidity associated with extreme prematurity.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/0194599820905528DOI Listing
April 2020

Competency-Based Assessment Tool for Pediatric Tracheotomy: International Modified Delphi Consensus.

Laryngoscope 2020 11 10;130(11):2700-2707. Epub 2019 Dec 10.

Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Pediatric Otolaryngology, Doernbecher Children's Hospital, Portland, Oregon, U.S.A.

Objectives/hypothesis: Create a competency-based assessment tool for pediatric tracheotomy.

Study Design: Blinded, modified, Delphi consensus process.

Methods: Using the REDCap database, a list of 31 potential items was circulated to 65 expert surgeons who perform pediatric tracheotomy. In the first round, items were rated as "keep" or "remove," and comments were incorporated. In the second round, experts were asked to rate the importance of each item on a seven-point Likert scale. Consensus criteria were determined a priori with a goal of 7 to 25 final items.

Results: The first round achieved a response rate of 39/65 (60.0%), and returned questionnaires were 99.5% complete. All items were rated as "keep," and 137 comments were incorporated. In the second round, 30 task-specific and seven previously validated global rating items were distributed, and the response rate was 44/65 (67.7%), with returned questionnaires being 99.3% complete. Of the Task-Specific Items, 13 reached consensus, 10 were near consensus, and 7 did not achieve consensus. For the 7 previously validated global rating items, 5 reached consensus and two were near consensus.

Conclusions: It is feasible to reach consensus on the important steps involved in pediatric tracheotomy using a modified Delphi consensus process. These items can now be considered to create a competency-based assessment tool for pediatric tracheotomy. Such a tool will hopefully allow trainees to focus on the important aspects of this procedure and help teaching programs standardize how they evaluate trainees during this procedure.

Level Of Evidence: 5 Laryngoscope, 130:2700-2707, 2020.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/lary.28461DOI Listing
November 2020

Pediatric adenoidectomy in the very young child and indications for postoperative inpatient admission.

Int J Pediatr Otorhinolaryngol 2020 Mar 25;130:109796. Epub 2019 Nov 25.

Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, 19104, USA; Department of Otorhinolaryngology - Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, 19104, USA. Electronic address:

Objectives: To determine the rate of significant respiratory events following adenoidectomy in young patients and to identify factors that would prompt inpatient admission postoperatively.

Methods: A retrospective chart review was performed of consecutive adenoidectomy surgeries at a high-volume, tertiary-care children's hospital between 2016 and 2018. Children under 3.5 years of age who had surgery for obstructive symptoms were included. Patients were grouped by age (youngest ≤1.5 years, middle 1.6-2.5 years, and oldest 2.6-3.5 years). We excluded patients having revision surgery, a concomitant tonsillectomy, or additional major surgical procedure.

Results: There were 353 patients that met inclusion criteria. The three age groups were similar with respect to all characteristics except age (p < .001), body mass index (p < .001), and percentage of Black or African American children (p = .02). Patients under 1.5 years more often had preoperative polysomnography (p = .02) with a lower oxygen saturation nadir (p = .04), and were more likely to have surgery for obstructive sleep apnea (p < .001). No differences were found between age groups with respect to recovery room issues, nurse triage calls, or readmissions within 30 days of surgery. An elective admission rate in the cohort was 35.1%, and this was age-group dependent with 79.5% of the youngest group being admitted (p < .001). On admission, 16.9% of all patients had admission events requiring positive pressure support, intensive care unit admission, or prolonged hospitalization, which was similar across all age groups (p = .67). Events were more common in younger patients (17 mos. vs 20 mos., p = .07), those with more comorbidities (74.8% vs 51.5%, p = .06) and significantly higher in those with severe preoperative polysomnogram variables (p < .001). Based on multivariate regression analysis, younger children (OR: 13.7, 95% CI: 6.5 - 29.0, p < .001) or children with an AHI over 5 events/hr (OR: 32.3, 95% CI: 3.4 - 303.2, p = .005) were more likely to have significant events on admission.

Conclusions: Significant respiratory events are uncommon after adenoidectomy for obstructive symptoms, even in very young children. However, for children under 1.5 years of age or those with AHI scores above 5 events/hr, postoperative admission for monitoring is recommended. Clinical judgement should be used when considering outpatient surgery for older children or those with comorbidities.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijporl.2019.109796DOI Listing
March 2020

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

Int J Pediatr Otorhinolaryngol 2020 Jan 28;128:109697. Epub 2019 Sep 28.

Department Pediatric Surgery, Bambino Gesù Pediatric Hospital, Rome, Italy.

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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijporl.2019.109697DOI Listing
January 2020

Advancements in Clinical Laryngology.

Otolaryngol Clin North Am 2019 Aug 14;52(4):xv-xvi. Epub 2019 May 14.

Pediatric Voice Program, Children's Hospital of Philadelphia, Otolaryngology: Head & Neck Surgery, Perelman School of Medicine, University of Pennsylvania, 3401 Civic Center Boulevard, 1 Wood Ent, Philadelphia, PA 19104, USA. Electronic address:

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.otc.2019.04.002DOI Listing
August 2019

Pediatricians' proficiency in the care of the dysphonic child.

Laryngoscope 2019 08 19;129(8):1756-1762. Epub 2018 Nov 19.

Department of Otolaryngology, Columbia University Voice and Swallowing Institute, New York, New York.

Objectives/hypothesis: Pediatricians are the first physicians to see a dysphonic child (DC), yet there are limited data on their proficiency in caring for them. The objective of this study was to understand how pediatricians' experience and their comfort in recognizing/diagnosing voice disorders affects their referral patterns and use of basic treatment options.

Study Design: Survey study.

Methods: A 13-question survey was sent to pediatricians in the Children's Hospital of Philadelphia's primary care network; 45/216 were returned. Statistical analyses were performed using the Student t test, linear/logistic regression model, Fisher exact test, Kruskal-Wallis test, and Spearman's correlation test.

Results: Pediatricians practicing longer are more comfortable recognizing dysphonia (P = .0022). They are significantly more likely to refer a DC, even without subjective complaints of hoarseness by the family/patient or compounding medical issues. For each year in practice, the probability of referring increases by 1.55% (P = .0017). Pediatricians with a higher percentage of dysphonic children in their practice are more likely to trust their own perceptual recognition when deciding to refer (P = .0496). Nearly all pediatricians (40/45) would refer to a pediatric otolaryngologist. None would refer to a laryngologist or a voice therapist. No factors significantly affected treatment options.

Conclusions: Veteran pediatricians feel more comfortable diagnosing a voice disorder and are more likely to refer a DC, regardless of patient/parent complaints or compounding factors. Pediatricians are most likely to refer to a pediatric otolaryngologist versus a voice specialist. These findings suggest that education of younger, less-experienced pediatricians about recognizing voice disorders and options for referral is needed. This may improve the overall care of the DC.

Level Of Evidence: 4 Laryngoscope, 129:1756-1762, 2019.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/lary.27577DOI Listing
August 2019

What is new with 22q? An update from the 22q and You Center at the Children's Hospital of Philadelphia.

Am J Med Genet A 2018 10;176(10):2058-2069

Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.

22q11.2 deletion syndrome (22q11.2DS) is a disorder caused by recurrent, chromosome-specific, low copy repeat (LCR)-mediated copy-number losses of chromosome 22q11. The Children's Hospital of Philadelphia has been involved in the clinical care of individuals with what is now known as 22q11.2DS since our initial report of the association with DiGeorge syndrome in 1982. We reviewed the medical records on our continuously growing longitudinal cohort of 1,421 patients with molecularly confirmed 22q11.2DS from 1992 to 2018. Most individuals are Caucasian and older than 8 years. The mean age at diagnosis was 3.9 years. The majority of patients (85%) had typical LCR22A-LCR22D deletions, and only 7% of these typical deletions were inherited from a parent harboring the deletion constitutionally. However, 6% of individuals harbored other nested deletions that would not be identified by traditional 22q11.2 FISH, thus requiring an orthogonal technology to diagnose. Major medical problems included immune dysfunction or allergies (77%), palatal abnormalities (67%), congenital heart disease (64%), gastrointestinal difficulties (65%), endocrine dysfunction (>50%), scoliosis (50%), renal anomalies (16%), and airway abnormalities. Median full-scale intelligence quotient was 76, with no significant difference between individuals with and without congenital heart disease or hypocalcemia. Characteristic dysmorphic facial features were present in most individuals, but dermatoglyphic patterns of our cohort are similar to normal controls. This is the largest longitudinal study of patients with 22q11.2DS, helping to further describe the condition and aid in diagnosis and management. Further surveillance will likely elucidate additional clinically relevant findings as they age.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/ajmg.a.40637DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6501214PMC
October 2018

Vocal Fold Motion Impairment.

Authors:
Karen B Zur

Curr Probl Pediatr Adolesc Health Care 2018 04 10;48(4):124-128. Epub 2018 Apr 10.

Center for Pediatric Airway Disorders, The Children's Hospital of Philadelphia, Philadelphia, PA; Otolaryngology: Head & Neck Surgery, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA. Electronic address:

Vocal fold motion abnormalities in children are the second most common form of laryngeal pathology seen in children, and often present in the first 24 months of life. A thorough evaluation of the aerodigestive tract will include an examination of the vocal folds, and a proper diagnosis is essential in order to decipher the etiology of swallowing, voicing and breathing abnormalities. This article reviews the workup, management options and clinical outcomes of unilateral and bilateral vocal fold motion impairment in the pediatric population.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.cppeds.2018.03.004DOI Listing
April 2018

Structure and Functions of Pediatric Aerodigestive Programs: A Consensus Statement.

Pediatrics 2018 03 7;141(3). Epub 2018 Feb 7.

Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee.

Aerodigestive programs provide coordinated interdisciplinary care to pediatric patients with complex congenital or acquired conditions affecting breathing, swallowing, and growth. Although there has been a proliferation of programs, as well as national meetings, interest groups and early research activity, there is, as of yet, no consensus definition of an aerodigestive patient, standardized structure, and functions of an aerodigestive program or a blueprint for research prioritization. The Delphi method was used by a multidisciplinary and multi-institutional panel of aerodigestive providers to obtain consensus on 4 broad content areas related to aerodigestive care: (1) definition of an aerodigestive patient, (2) essential construct and functions of an aerodigestive program, (3) identification of aerodigestive research priorities, and (4) evaluation and recognition of aerodigestive programs and future directions. After 3 iterations of survey, consensus was obtained by either a supermajority of 75% or stability in median ranking on 33 of 36 items. This included a standard definition of an aerodigestive patient, level of participation of specific pediatric disciplines in a program, essential components of the care cycle and functions of the program, feeding and swallowing assessment and therapy, procedural scope and volume, research priorities and outcome measures, certification, coding, and funding. We propose the first consensus definition of the aerodigestive care model with specific recommendations regarding associated personnel, infrastructure, research, and outcome measures. We hope that this may provide an initial framework to further standardize care, develop clinical guidelines, and improve outcomes for aerodigestive patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1542/peds.2017-1701DOI Listing
March 2018

Recurrent laryngeal nerve reinnervation for management of aspiration in a subset of children.

Int J Pediatr Otorhinolaryngol 2018 Jan 6;104:104-107. Epub 2017 Nov 6.

Pediatric Otolaryngology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, 1 Wood ENT, Philadelphia, PA 19104, USA. Electronic address:

Pediatric aspiration is a multifactorial process that is often complex to manage. Recurrent laryngeal nerve (RLN) injury can cause glottic insufficiency and aspiration. We describe three cases of unilateral vocal fold paralysis resulting in aspiration and the successful use of the RLN reinnervation for its treatment. The theory for utilizing the reinnervation procedure is that when glottic closure improves and a less breathy vocalization occurs, then the larynx is better equipped to protect the lower airway and avoid aspiration. Our cases demonstrate stronger voice and improved swallow function, with normalization of modified barium swallow evaluation, at approximately 6-months post reinnervation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijporl.2017.11.002DOI Listing
January 2018

International Pediatric Otolaryngology Group: Consensus guidelines on the diagnosis and management of type I laryngeal clefts.

Int J Pediatr Otorhinolaryngol 2017 Oct 18;101:51-56. Epub 2017 Jul 18.

Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, MA, USA.

Introduction: The diagnosis and management of type I laryngeal clefts can be controversial and varies across centers and surgeons. Using existing peer-reviewed literature to develop an expert-based consensus will help guide physicians in the treatment of these patients as well as develop research hypotheses to further study this condition.

Objective: To provide recommendations for the diagnosis and management of type I laryngeal clefts.

Methods: Determination of current expert- and literature-based recommendations, via a survey of the International Pediatric Otolaryngology Group, using a modified Delphi method.

Setting: Multinational, multi-institutional, tertiary pediatric hospitals.

Results: Consensus recommendations include diagnostic workup, medical management, pre-operative, intra-operative and post-operative considerations for type I laryngeal clefts.

Conclusions: This guide on the diagnosis and management of patients with type I laryngeal clefts is aimed at improving patient care and promoting future hypothesis generation and research to validate the recommendations made here.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijporl.2017.07.016DOI Listing
October 2017

Systemic bevacizumab for recurrent respiratory papillomatosis: A national survey.

Laryngoscope 2017 10 28;127(10):2225-2229. Epub 2017 Jun 28.

Pediatric Otolaryngology, The Children's Hospital of Philadelphia, The University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A.

Objectives/hypothesis: Aggressive laryngeal, tracheal, and pulmonary papilloma is an extremely challenging clinical problem without proven treatment options. A recent German report documented promising results with systemic bevacizumab. The objective of this study is to report the initial experience of this novel treatment in the United States for recurrent respiratory papillomatosis (RRP).

Study Design: Cases series.

Methods: Electronic survey of the RRP Task Force of the American Society of Pediatric Otolaryngology, American Broncho-Esophagological Association, and physicians known to the authors to have used systemic bevacizumab for RRP.

Results: Eleven completed surveys were obtained. In three cases, systemic bevacizumab was considered clinically but not administered. Eight patients were treated with systemic bevacizumab, all for aggressive papillomatosis uncontrolled by surgical and adjuvant therapy, including seven of eight with pulmonary disease. Treatment dosing ranged from 5 to 10 mg/kg every 2 to 4 weeks, with all patients responding (7/8 partial response, 1/8 complete response). In four patients who had postbevacizumab chest imaging, three demonstrated improvement of disease and one stabilization. Treatment interval could be lengthened in seven patients and clinical response maintained. One patient with long-standing pulmonary disease (>10 years) was diagnosed with malignant transformation while on treatment, and bevacizumab was discontinued in lieu of other chemotherapeutic agents. All other patients continue on systemic bevacizumab with minimal complications (hemoptysis n = 1, proteinuria n = 1).

Conclusions: Systemic bevacizumab appears to have significant promise in the most treatment-resistant and aggressive forms of papillomatosis with a low complication profile. These results suggest bevacizumab should be studied in a formal clinical trial for RRP.

Level Of Evidence: 4. Laryngoscope, 127:2225-2229, 2017.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/lary.26662DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5607082PMC
October 2017

Association of airway abnormalities with 22q11.2 deletion syndrome.

Int J Pediatr Otorhinolaryngol 2017 May 21;96:11-14. Epub 2017 Feb 21.

22q and You and Clinical Genetics Centers, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA. Electronic address:

Introduction: 22q11.2 deletion syndrome (22q11.2DS) presents with complex but variable symptoms, including cardiac, immune, palatal, endocrine, cognitive, and psychiatric issues. However, an association of 22q11.2DS with structural airway abnormalities has not been formally described. The aim of this study was to document the frequency of this association.

Methods: We retrospectively reviewed medical records of patients with 22q11.2DS evaluated in the 22q and You Center at the Children's Hospital of Philadelphia between 1999 and 2015 referred to otolaryngology for an airway assessment. Type of airway abnormality and presence of comorbidities, such as congenital heart disease, tracheostomy, and association with prenatal symptomatology such as polyhydramnios, were noted.

Results: Of the 104 patients who underwent an otolaryngology procedure (microlaryngoscopy or bronchoscopy), 71% (n = 74) had airway abnormalities. Patients with airway abnormalities ranged in age from 5 months to 37 years, with similar prevalence among males and females. Observed airway abnormalities included tracheomalacia (36%), subglottic stenosis (28%), laryngomalacia (26%), glottic web (21%), and bronchomalacia (16%). Most patients with airway abnormalities (91%) had an associated congenital heart defect, with ventricular septal defect and Tetralogy of Fallot being the most prevalent. Importantly, 30% of patients required a tracheostomy, and overall polyhydramnios was noted in 16% of pregnancies.

Conclusion: Airway abnormalities are a common feature of 22q11.2DS, leading to substantial morbidity, particularly when combined with complex cardiac disease. Polyhydramnios may be an important prenatal clue to both the diagnosis of 22q11.2DS and airway anomalies. Postnatal assessment of airway structure and function among patients with 22q11.2DS is an important component of overall evaluation and will help guide long-term management.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijporl.2017.02.012DOI Listing
May 2017

Bevacizumab chemotherapy for management of pulmonary and laryngotracheal papillomatosis in a child.

Laryngoscope 2017 07 20;127(7):1538-1542. Epub 2016 Dec 20.

Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A.

Recurrent laryngeal papillomatosis (RRP) can be a devastating condition for a child to endure, and pulmonary involvement may have terminal consequences. Adjuvant therapies have been trialed and reported over the years; however, these chemotherapy options have not been successful. Bevacizumab (Avastin, Genetech Inc., South San Francisco, CA) is a vascular endothelial factor (VEGF) inhibitor that has shown promise in the management of papillomatosis. Most research has focused on intralesional injections of this antiangiogenic drug. The systemic use of bevacizumab is not as well described. This is a case report of a 12-year-old female diagnosed with severe laryngotracheal papillomatosis near birth who underwent a tracheostomy tube placement at 1 year of age. She required weekly debridements to prevent tracheal obstruction. When lung involvement was diagnosed at 1 year of age, cidofovir was started intravenously. Over the course of the past 10 years, the patient was managed with celecoxib (Celebrex, Pfizer, New York, NY), anti-reflux medications, zithromycin, propranolol, Gardasil (Merck and Co., Kenilworth, NJ), and a 7-year course of interferon-alpha. Intravenous bevacizumab was started when the patient's pulmonary status deteriorated. There was remarkable improvement in her laryngotracheal disease within 6 weeks of therapy. Following 3 months of bevacizumab, the patient's disease was completely resolved at the laryngeal level and nearly gone in the trachea, and she was decannulated. A computed scan was performed following 5 months of intravenous bevacizumab, and the pulmonary RRP nodules completely resolved. The patient had no major or minor complication from the chemotherapy to date. Systemic Bevacizumab is a promising modality of adjuvant therapy for significant papillomatosis. Laryngoscope, 127:1538-1542, 2017.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/lary.26450DOI Listing
July 2017

Recurrent laryngeal nerve reinnervation in children: Acoustic and endoscopic characteristics pre-intervention and post-intervention. A comparison of treatment options.

Laryngoscope 2015 Dec 8;125 Suppl 11:S1-15. Epub 2015 Aug 8.

Department of Pediatric Otolaryngology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A.

Objectives/hypothesis: To establish the benefit of ansa cervicalis-recurrent laryngeal nerve reinnervation (ANSA-RLN) for the management of dysphonia secondary to unilateral vocal cord paralysis (UVCP) in children. Children treated with ANSA-RLN for the management of dysphonia secondary to unilateral vocal fold immobility will have superior acoustic, perceptual, and stroboscopic outcomes compared to injection laryngoplasty and observation.

Study Design: Retrospective case-series chart review.

Methods: Laryngeal, perceptual, and acoustic analysis of dysphonia was performed in 33 children (age 2-16 years) diagnosed with UVCP. Comparison of pre-post function for treatment groups (no treatment, injection laryngoplasty, ANSA-RLN) with additional comparison between gestational ages, age at initial evaluation, and gender were examined. Perceptual measures included Pediatric Voice Handicap Index (pVHI) and Grade, Roughness, Breathiness, Asthenia, Strain (GBRAS) perceptual rating. Objective measures included semitone (ST) range, jitter%, shimmer%, noise-to-harmonic ratio, voicing, and maximum phonation time.

Results: Post-treatment, pVHI, jitter%, and ST were significantly improved for ANSA-RLN subjects compared to injection subjects. Improved function (laryngeal diadochokinesis, pVHI, GRBAS, and/or acoustic) was observed in all ANSA-RLN subjects who had vocal fold paralysis as the only laryngeal diagnosis.

Conclusions: This study presents one of the largest studies of pediatric vocal fold paralysis diagnosis and treatment. The study looks at the spectrum of function in patients with UVCP and looks at the outcomes of options: no treatment, injection laryngoplasty, and ANSA-RLN. Although surgical outcomes vary, both injection laryngoplasty and ANSA-RLN show benefit in laryngeal function, voice stability, voice capacity, perceptual rating, and pVHI scores. Both injection laryngoplasty and ANSA-RLN showed improvements post-treatment, and should be considered for management of pediatric UVCP. However, the ANSA-RLN group showed better and longer-lasting perceptual and acoustic parameters in comparison with the injection and control groups. Reinnervation, even long term after the onset of vocal fold paralysis, should be considered a viable permanent treatment for pediatric UVCP.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/lary.25538DOI Listing
December 2015

Severity of voice handicap in children diagnosed with elevated lesions.

Otolaryngol Head Neck Surg 2013 Oct 19;149(4):628-32. Epub 2013 Aug 19.

Division of Otolaryngology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.

Objective: This study sought to determine the impact of voice disability on children with elevated vocal fold lesions (nodules, cysts, polyps). The Pediatric Voice Handicap Index (pVHI) was used to assess the impact on functional, physical, and emotional aspects of voice and oral communication. The degree of talkativeness and overall severity of dysphonia were also determined.

Study Design: Case series with chart review of children evaluated at a voice clinic from 2007 to 2011.

Setting: Tertiary specialized children's hospital.

Subjects And Methods: Medical records of 33 children (11 girls, 22 boys) diagnosed with an elevated vocal fold lesion by a pediatric laryngologist were reviewed for voice disability using the pVHI. The pVHI is a parental proxy of perceived voice handicap in functional, physical, and emotional aspects and includes a talkativeness rating scale and visual analog overall severity rating of voice (VAS). Data were examined for young children (age 2-5 years), children (age 6-10 years), and adolescents (age 11-17 years).

Results: The VAS was significantly correlated with pVHI-total. There was no significant difference between age groups for overall pVHI (mean, 29.3) or talkativeness, but all groups had significantly higher functional disability (mean, 16) compared with physical (mean, 8.2) or emotional (mean, 5.1) disability.

Conclusions: Children across all age groups with elevated vocal fold lesions have significant voice disability, greatest for functional aspects of voice. Voice care team professionals must recognize the functional impact of dysphonia on the pediatric patient.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/0194599813500641DOI Listing
October 2013

Recurrent laryngeal nerve reinnervation for unilateral vocal fold immobility in children.

Authors:
Karen B Zur

Laryngoscope 2012 Dec;122 Suppl 4:S82-3

Department of Otolaryngology-Head and Neck Surgery, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/lary.23815DOI Listing
December 2012