David L. Mandell

A preliminary report on micronized AlloDerm injection laryngoplasty

Objectives To report the preliminary data of voice and quality‐of‐life improvement after micronized AlloDerm injection laryngoplasty in patients with unilateral vocal cord paralysis.

Correction of upper airway obstruction in the newborn with internal mandibular distraction osteogenesis.

Tracheostomy for management of neonatal airway obstruction may be life saving but is associated with complications and developmental problems. As an alternative, the effectiveness of internal mandibular distraction osteogenesis was investigated in select neonatal patients with micrognathia and upper airway obstruction. Preoperative tests (sleep study, direct laryngobronchoscopy, and “milk scan” for GI reflux) were used to select appropriate candidates for the procedure. Excluded were patients with 1) central apnea, 2) severe reflux, 3) other airway lesions, and 4) mild to moderate obstruction controlled by positioning. Of 44 newborns (aged <3 weeks) with upper airway obstruction and micrognathia seen in the neonatal intensive care unit, 19 underwent tracheostomy, 10 were discharged with home monitoring and positional instructions, and 15 underwent bilateral mandibular lengthening with microdistractors. Of those who underwent mandibular distraction, a tracheostomy was avoided in 14 of 15 patients. Relative improvement in the posterior airway space was seen on 3D CT scans, cephalograms, and laryngobronchoscopies obtained preoperatively, postoperatively, and during follow-up evaluation. One of these 15 patients required a tracheostomy for postoperative central apnea. In an average of just 4.5 days following completion of distraction, patients were discharged home with improved oral feeding and no feeding tube. This study suggests that for selected newborns, the use of internal microdistractors allows for avoidance of a tracheostomy and improved oral feeding.

Laryngomalacia induced by exercise in a pediatric patient.

Exercise-induced laryngomalacia (EIL) is characterized by inspiratory stridor that is brought on by exercise (i.e. competitive sports) and fails to respond to treatment with bronchodilators (Smith et al., Ann Otol Rhinol Laryngol 1995;104:537-541). During exercise, (1) spirometric flow volume loops show evidence of variable extrathoracic obstruction, and (2) laryngoscopy shows inspiratory prolapse of supraglottic structures with partial glottic obstruction. Only five cases of probable EIL have been reported in the literature (Smith et al., Ann Otol Rhinol Laryngol 1995;104:537-541; Lakin et al., Chest 1984;86:499-501; Bittleman et al., Chest 1994;106:615-616; Bent et al., Ann Otol Rhinol Laryngol 1996;105:169-175; Chemery et al., Rev Mal Respir 2002;19:641-643). Here, a case of laryngomalacia induced by exercise in a previously asymptomatic 10-year-old athlete with a remote history of laryngomalacia in infancy is presented, and a review of previously reported cases is provided.

Comparison of Pediatric Voice Outcome Survey, Reflux Symptom Index, Reflux Finding Score, and Esophageal Biopsy Results

OBJECTIVE To examine correlations between the Pediatric Voice Outcome Survey (PVOS) score, the Reflux Symptom Index (RSI) score, the Reflux Finding Score (RFS), and esophageal biopsy findings in children undergoing upper aerodigestive tract endoscopy. DESIGN Retrospective review of pediatric voice quality-of-life and laryngopharyngeal reflux surveys. Blinded assessment of endoscopic laryngeal images. SETTING Tertiary care childrens hospital. PATIENTS The study included 36 children with the primary problem of dysphonia (n = 28) or cough (n = 8) who underwent endoscopy. INTERVENTIONS The PVOS and the RSI were administered to the patients parents before surgery. The patients underwent laryngotracheobronchoscopy and esophageal biopsy. Four raters independently assigned an RFS to the laryngeal photographs. MAIN OUTCOME MEASURES The assessment included (1) PVOS scores, RSI scores, and RFSs; (2) internal consistency of PVOS and RSI scores; (3) RFS intrarater and interrater reliability; and (4) correlations between PVOS score, RSI score, RFS, and esophageal biopsy findings. RESULTS The mean (SD) age of the patients was 7.5 (2.6) years; the mean (SD) PVOS score, 71.9 (21.4); and the mean (SD) RSI score, 16.2 (9.1). The PVOS and the RSI scores demonstrated good internal consistency (Cronbach alpha = 0.79 and 0.78, respectively). The RFS exhibited good intrarater reliability (r = 0.66-0.98) and moderate interrater reliability (r = 0.32-0.70). The PVOS and RSI instruments displayed significant correlation (r = -0.30; P = .04). There were no other significant correlations between RFSs, esophageal biopsy results, PVOS scores, or RSI scores (P > .05). CONCLUSIONS The RSI may be a useful parent-proxy instrument in addition to the PVOS for pediatric voice patients. The RFS is reliable in children, but its validity could not be demonstrated in this patient population.

Laryngomalacia and swallowing function in children.

1) To determine the prevalence of dysphagia in children with laryngomalacia, 2) To ascertain whether severity of laryngomalacia influences the presence of swallowing dysfunction, and 3) To examine whether patients with medical comorbidities and laryngomalacia have a higher prevalence of swallowing dysfunction.

Videolaryngostroboscopy following Vertical Partial Laryngectomy

Phonation after partial laryngeal ablative surgery has not often been examined. Videolaryngostroboscopic recordings made after vertical partial laryngectomy (VPL) were retrospectively reviewed and correlated with patient historical and operative factors. Among VPL patients (n = 42), the most common site of vibration during phonation was the contralateral false vocal fold (17/42 patients or 40.5%), followed by the contralateral arytenoid mucosa (10/42 or 23.8%) and the contralateral true vocal fold (8/42 patients or 19.0%). There was no overall difference in vocal quality judgment with respect to site of vibration (ANOVA, p = .373). Vocal quality scores were similar with use of the pyriform mucosal flap versus other reconstructive methods (Students t-test, p = .568). This study highlights the fact that reconstruction of a new vibratory source after VPL is important for voice production. Because VPL patients infrequently demonstrated true vocal fold vibration, alternative sites (ie, false vocal fold, arytenoid mucosa) must be considered as new phonatory sources after VPL.

Clinical Predictors of Aspiration on Radionuclide Salivagrams in Children

OBJECTIVE To determine patient characteristics and clinical factors that are predictive of positive radionuclide salivagram results. DESIGN Retrospective chart review (spanning 32 months). SETTING Tertiary care childrens hospital. PATIENTS The study included 129 consecutive pediatric patients with suspected chronic aspiration. INTERVENTION All subjects underwent radionuclide salivagrams to evaluate for aspiration. MAIN OUTCOME MEASURES The association of 16 patient characteristics and clinical factors (eg, age, sex, diagnoses, study indications, medications, and previous surgical procedures) with salivagram results. Each factor was examined individually (chi(2) or Fisher exact test). For those factors that were significantly associated with positive salivagram results, the risk was estimated with the odds ratio (OR). A multivariable logistic regression model was constructed to determine how well significantly associated factors together predicted positive salivagram results. RESULTS The mean (SD) patient age was 4.5 (5.4) years. There were 84 boys (65%) and 45 girls (35%). Aspiration was identified in 27 of 129 salivagrams (21%). On univariate analysis, positive salivagram results were significantly associated with chronic respiratory infections and/or pneumonia (OR, 2.6), prescription of antireflux medications (OR, 2.7), developmental delay (OR, 2.8), and reactive airway disease exacerbations (OR, 3.3) (P<.05). None of the other clinical factors were significantly associated with salivagram results. On multivariate analysis, salivagram results were significantly associated with the 4 above-mentioned factors (P = .009). However, these 4 predictive factors were not independent of each other owing to the statistically significant associations among them. CONCLUSIONS We identified 4 clinical factors that are predictive of aspiration on salivagram. A high level of suspicion for aspiration should be maintained in children with these potential risk factors.

Assessment of Constipation in Children With Tracheostomy

OBJECTIVE To determine the prevalence of constipation among children with tracheostomy tubes compared with children without tracheostomy tubes. We theorize that patients with tracheostomy may be unable to achieve adequate subglottic pressure for the Valsalva maneuver, which may contribute to constipation. DESIGN Prospective cohort study. SETTING Tertiary care childrens hospital. PATIENTS Consecutive series of 36 children with tracheostomy and 72 general pediatric otolaryngology patients without tracheostomy. INTERVENTIONS A pediatric constipation questionnaire (from previously published references) was given to parents of the study participants. Data were collected regarding patient medications, neurological status, and use of positive pressure airway assistance, speaking valves, and feeding tubes. Data were evaluated using chi(2) and t tests. Logistic regression analysis was used to search for independent variables impacting presence of constipation. RESULTS The mean ages for the tracheostomy and control groups were 6.8 and 4.7 years, respectively (P = .07). A history of constipation was elicited in 60% of children with tracheostomy compared with only 16.7% of controls (P < .001). More patients with tracheostomy tubes (80.0%) than controls (20.8%) were taking medication to treat constipation (P < .001). Constipation was also significantly associated with older age (P = .02), use of medications with constipation as a known adverse effect (P = .02), and the presence of neurodevelopmental impairment (P < .001). Constipation was still independently associated with the presence of a tracheostomy tube when correcting for age and the use of constipation-causing medications. When controlling for neurodevelopmental impairment, the presence of a tracheostomy tube was not proven to be an independent predictor of constipation. CONCLUSION Children with tracheostomy tubes are more likely to have a history of constipation, although a causal relationship between tracheostomy and constipation could not be determined due to the potentially confounding variable of neurodevelopmental delay.

09:00: RNA Interference Knockdown of TGF-B2 in Human Fibroblasts

portional to the growth stage: immature or proliferating tissues showed a higher concentration of SKI, whereas, mature lesions stained less intensely. The endothelial cells which were SKIpositive were involved in active cell division. CONCLUSION: The SKI oncogene protein is differentially and specifically expressed in hemangioma tissues. SKI acts as a transcriptional co-repressor and inhibits the TGF-b pathway, thus leading to uncontrolled cellular proliferation and transformation. All controls were negative for SKI staining. SIGNIFICANCE: The SKI oncogene protein is a new hemangioma-specific marker and is involved in hemangioma tumorigenesis. SUPPORT: Vascular Birthmark Foundation.

11:40: Microdebrider vs. Electrocautery Wound Healing Histopathology

lator. With the caveat of the potential for a more painful postoperative course, the results indicate that the suction coagulator has a better postoperative profile than curettage. The pathophysiology of the pain due to use of the suction coagulator should be further researched. SIGNIFICANCE: These results indicate that, in some instances, the suction coagulator should be the method of choice rather than curettage, especially if bleeding is a prime concern. SUPPORT: Supported by a medical student research bursary from the Canadian Institut of Health Reaserch.