David L. Horn

Divergence of Fine and Gross Motor Skills in Prelingually Deaf Children: Implications for Cochlear Implantation

Objective: The objective of this study was to assess relations between fine and gross motor development and spoken language processing skills in pediatric cochlear implant users.

Development of visual attention skills in prelingually deaf children who use cochlear implants.

Objective: To determine the effects of length of cochlear implant use and other demographic factors on the development of sustained visual attention in prelingually deaf children and to examine the relations between performance on a test of sustained visual attention and audiological outcome measures in this population. Design: A retrospective analysis of data collected before cochlear implantation and over several years after implantation. Two groups of prelingually deaf children, one >6 years old (N = 41) and one <6 years old (N = 47) at testing, were given an age-appropriate Continuous Performance Task (CPT). In both groups, children monitored visually presented numbers for several minutes and responded whenever a designated number appeared. Hit rate, false alarm rate, and signal detection parameters were dependent measures of sustained visual attention. We tested for effects of a number of patient variables on CPT performance. Multiple regression analyses were conducted to determine if CPT scores were related to performance on several audiological outcome measures. Results: In both groups of children, mean CPT performance was low compared with published norms for normal-hearing children, and performance improved as a function of length of cochlear implant use and chronological age. The improvement in performance was manifested as an increase in hit rate and perceptual sensitivity over time. In the younger age group, a greater number of active electrodes predicted better CPT performance. Results from regression analyses indicated a relationship between CPT response criterion and receptive language in the younger age group. However, we failed to uncover any other relations between CPT performance and speech and language outcome measures. Conclusions: Our findings suggest that cochlear implantation in prelingually deaf children leads to improved performance on a test of sustained visual processing of numbers over 2 or more years of cochlear implant use. In preschool-age children who use cochlear implants, individuals who are more conservative responders on the CPT show higher receptive language scores than do individuals with more impulsive response patterns. Theoretical accounts of these findings are discussed, including cross-modal reorganization of visual attention and enhanced phonological encoding of visually presented numbers.

Dynamic range enhancement for cochlear implants.

Hypothesis The addition of a continuous, unmodulated, high-rate pulse train to sinusoidal stimuli presented by the cochlear implant to implant recipients will result in increases in the psychophysical dynamic range. Background The hearing dynamic range of cochlear implant patients is markedly reduced compared with that of normal-hearing individuals. This has negative implications for both speech perception and sound quality in these patients. It has been suggested that the addition of an unmodulated high-rate pulse train to deafened auditory nerves could create spontaneous-like neural activity, similar to that recorded from normal ears, of which one significant benefit would be an increase in the dynamic range of cochlear implant users. Methods Twenty-nine patients who underwent implantation with the Clarion CII device participated in this single-blinded prospective study. The psychophysical dynamic range of 28 of these subjects was measured with sinusoidal stimuli in response to various levels of an additional unmodulated high-rate pulse train. Results All the tested subjects (n = 28) demonstrated an increase in dynamic range in response to an appropriate level of unmodulated high-rate pulse train. The largest increase in dynamic range for each subject had a mean value of 6.7 dB. Conclusion The addition of an unmodulated high-rate pulse train to the electric signal presented to cochlear implant patients results in significant increases in dynamic range for sinusoidal stimuli.

A New Scoring System for Upper Airway Pediatric Sleep Endoscopy

IMPORTANCE Sleep-associated upper-airway obstruction in children is a significant cause of morbidity. Development of a simple, standardized, quantitative technique to assess anatomic causes of sleep-related breathing disorder is important for surgical planning, clinical communication, and research. OBJECTIVE To design, implement, and evaluate a scoring system to quantify airway obstruction in pediatric drug-induced sleep endoscopy. DESIGN, SETTING, AND PARTICIPANTS This study was a retrospective case series conducted at a tertiary pediatric hospital. The patients were children with sleep-related breathing disorder who underwent polysomnography and drug-induced sleep endoscopy. INTERVENTIONS Flexible fiber-optic laryngoscopy was performed. Endoscopic examinations were recorded on video and assessed by 4 independent raters based on a scoring template. MAIN OUTCOMES AND MEASURES Five locations in the upper aerodigestive tract (adenoid, velum, lateral pharyngeal wall, tongue base, and supraglottis) were evaluated on a 4-point scale for minimum and maximum obstruction. Internal reliability was assessed by calculating interrater and intrarater intraclass correlation coefficients (ICCs). For external validation, aggregate and site-specific scores were correlated with preoperative polysomnographic indices. RESULTS Videos recorded of sleep endoscopies from 23 children (mean age, 2.2 years) were reviewed and rated. Children had an average apnea-hypopnea index of 24.8. Seventy percent of interrater and intrarater ICC values (7 of 10 for each set) were above 0.6, demonstrating substantial agreement. Higher total obstructive scores were associated with lower oxygen saturation nadir (P = .04). The scoring system was also used to quantitatively identify children with multilevel airway obstruction, who were found to have significantly worse polysomnographic indices compared with children with single-level obstruction (P = .02). CONCLUSIONS AND RELEVANCE The proposed scoring system, which is designed to be easy to use and allow for subjectivity in evaluating obstruction at multiple levels, nonetheless achieves good internal reliability and external validity. Implementing this system will allow for standardization of reporting for sleep endoscopy outcomes, as well as aid the practicing clinician in the interpretation of sleep endoscopy findings to inform site-directed surgical intervention in cases of complicated obstructive sleep apnea.

Visual-Motor Integration Skills of Prelingually Deaf Children: Implications for Pediatric Cochlear Implantation

Objective: To investigate visual‐motor integration (VI) skills of prelingually deaf (PLD) children before and after cochlear implantation (CI) and investigate correlations with spoken‐language and related processing measures.

Behavioral Assessment of Prelingually Deaf Children Before Cochlear Implantation

Objectives/Hypothesis: To determine whether scores from a behavioral assessment of prelingually deafened children who present for cochlear implant surgery are predictive of audiological outcomes

Interarytenoid Sodium Carboxymethylcellulose Gel Injection for Management of Pediatric Aspiration

Objective: This study aimed to investigate the role of interarytenoid injection laryngoplasty (IL) for the management of pediatric aspiration. Methods: Medical records of 30 patients, 9 female, with radiographically confirmed chronic aspiration who underwent intraoperative IL were retrospectively reviewed. Clinical improvement was defined as successful advancement of feeds to thinner consistencies. Results: Clinical improvement was observed in 57% of patients. Six children with type 1 posterior laryngeal cleft (PLC-1) were not significantly more likely to show improvement compared to the children without PLC-1. Type 1 posterior laryngeal cleft was associated with older age and higher prevalence of neurodevelopmental risk factors relative to absence of PLC-1. Patients with PLC-1 were more likely than noncleft patients to show recurrence of symptoms after initial improvement with IL. Five patients underwent endoscopic repair. Repair was successful in 3 patients who improved after IL but not in 2 patients who did not improve after IL. Conclusion: Chronic aspiration can improve after IL even in patients with normal anatomy. Injection laryngoplasty can be performed to improve selection of PLC-1 patients for definitive endoscopic repair. Further prospective research, with a randomized control group, is needed to understand whether interarytenoid incompetence plays a role in some patients with chronic aspiration, who do not have a PLC-1.

Supraglottoplasty for sleep endoscopy diagnosed sleep dependent laryngomalacia

OBJECTIVES To evaluate the polysomnographic outcomes of supraglottoplasty (SGP) performed for sleep endoscopy diagnosed sleep dependent laryngomalacia as treatment for obstructive sleep apnea syndrome (OSAS). METHODS Nine subjects aged 6-55 months underwent supraglottoplasty for sleep dependent laryngomalacia. All subjects underwent both pre- and post-procedural polysomnograms. RESULTS Supraglottoplasty for sleep dependent laryngomalacia resulted in improvement of OSAS as measured by collective improvements in 8 different primary polysomnogram parameters: apnea-hypopnea index (AHI), minimum (nadir) and mean oxygen saturation, mean and maximum carbon dioxide, total sleep time, sleep efficiency, arousal index, as well as improvement in weight for length percentiles. Subjects had a significant 80% decrease in percentage change in AHI (p<0.005), with decrease in mean AHI from 23.4 to 4.8 following supraglottoplasty. Seven of 9 subjects demonstrated improvement in nadir saturations, 6 of 9 subjects had improvement in sleep efficiency, and 7 of 8 subjects under 4 years of age had improvement in weight for length percentile. CONCLUSIONS Supraglottoplasty for sleep dependent laryngomalacia is an effective treatment of OSAS, and can be readily diagnosed using sleep endoscopy. Further investigation is warranted to increase awareness and outcomes related to sleep dependent laryngomalacia.

Behavioral Inhibition and Clinical Outcomes in Children with Cochlear Implants

Objectives/Hypothesis: Individual speech and language outcomes of deaf children with cochlear implants (CIs) are quite varied. Individual differences in underlying cognitive functions may explain some of this variance. The current study investigated whether behavioral inhibition skills of deaf children were related to performance on a range of audiologic outcome measures.

Imaging of pediatric floor of mouth lesions

There is a vast spectrum of pathology that afflicts the floor of mouth in children. These span inflammatory conditions, vascular malformations, developmental anomalies, benign tumors and malignancies. While this area is readily evaluated on clinical exam, imaging is often performed to better characterize the disorder prior to management. The imaging modalities most frequently utilized are US, CT and MR. The purpose of this article is to describe the primary conditions that occur in this location in children so that radiologists may provide an appropriate differential diagnosis. These include ranula, venolymphatic malformation, dermoid, teratoma, foregut duplication cyst, hairy polyp, thyroglossal duct cyst and rhabdomyosarcoma. For each pathological condition, there will be a focus on describing its imaging manifestation. Floor of mouth anatomy, imaging approach during both prenatal and postnatal life and etiologies will be discussed. Surgical considerations and operative photographs will also be presented.