David M. Wynne

Risk factors for failure of supraglottoplasty

OBJECTIVES To assess for identifiable risk factors for failed surgical intervention in children with laryngomalacia. METHODS Retrospective case note review between September 2007 and March 2012. Case notes were reviewed for demographic data, symptoms, co-morbidities, operative technique, postoperative recovery, complications, length of hospital stay including intensive care unit (ICU) care, and resolution of symptoms. RESULTS 148 children underwent supraglottoplasty. Case notes were available for 115 (78%) patients. 35% (41/115) of cases were females and 65% (74/115) were male. A bimodal age distribution was observed with peaks at 3 months and 3.5 years. Those over one year of age were more likely to have complications (p = 0.035). There was no significant difference in outcomes for age (p > 0.05). In patients less than one year, reflux symptoms were significantly associated with a higher likelihood of failure of the operation (p = 0.013). Patients under one year with pre-operatively identified comorbid conditions were less likely to have an improvement in breathing (p = 0.002). Cold steel was used in 55% (63/115) of cases, laser only in 17% (20/115) cases and a combination of the two techniques in 28%, (32/115). There was no association between the surgical technique used and complications (p = 0.558). There was no association between improvement in symptoms and surgical technique used (p = 0.560). There was a significant association between delayed post-operative neurological diagnosis and failure of the operation (p < 0.001). 21 (18%) patients required a second procedure. CONCLUSIONS Pre-operative predictors of failure were patients with reflux symptoms (p = 0.013). Patients that required a second procedure were 37 times more likely to have a delayed diagnosis of an underlying neurological condition. Failure of symptoms to improve after supraglottoplasty should alert the clinician to the possibility of an underlying neurological disorder.

Paediatric tracheostomy—An 11 year experience at a Scottish paediatric tertiary referral centre

AIMS The aim of this paper was to review the indications, complications and outcomes for tracheostomy at a Scottish paediatric tertiary referral hospital. METHODS All patients undergoing tracheostomy between January 2001 and September 2012 were identified. A retrospective case note analysis was performed. RESULTS 111 tracheostomies were done in the study period. The mean number per year was 11 (3-12). Full data was available for 95 patients. There were 56 (59%) males and 39 (41%) females. Age at time of tracheostomy ranged from one day to 15 years, the mean age of tracheostomy insertion was 69 weeks. The majority of patients, 75 (79%), were under one year old when they had their tracheostomy. The most common indication was long-term ventilation (20%), followed by craniofacial abnormality causing airway obstruction (18%), followed by subglottic stenosis (14%). 37% of patients were decannulated. CONCLUSIONS This series reflects current trends in the indications for paediatric tracheostomy, with chronic lung disease of prematurity being the most common indication.

Complications of Ventilation Tube Insertion in Children With and Without Cleft Palate: A Nested Case-Control Comparison

IMPORTANCE Optimizing hearing in patients with cleft lip and/or palate (CLP) by early recognition and management of otitis media with effusion is essential for speech development. Some evidence has suggested higher complication rates from ventilation tube (VT) insertion in patients with CLP and has led to a trend not to treat these patients surgically. However, studies have failed to match comparison groups for age and sex. OBJECTIVE To compare complication rates from VT insertion in pediatric patients with and without CLP. DESIGN, SETTING, AND PARTICIPANTS The study used a nested case-control design to evaluate 60 pediatric patients with CLP who underwent VT insertion at a childrens hospital. The control group of age- and sex-matched patients was selected from a database of 2943 VT insertions. INTERVENTIONS All patients were administered general anesthesia and underwent VT insertion by a pediatric otorhinolaryngology (ENT) team. MAIN OUTCOMES AND MEASURES The primary outcomes were numbers of otorrhea complications. Secondarily, rates of attendance at an ENT clinic specifically for complications were evaluated. Finally, numbers of complications other than otorrhea were assessed but not statistically analyzed owing to the varied types and low numbers in each group. RESULTS The control cohort had 151 documented cases of otorrhea compared with 121 in the CLP group (ratio 1.25:1); the difference between groups was not statistically significant (P = .52). There was no significant difference in mean ENT clinic visits per patient for complications between groups (0.80 in the CLP group, 0.78 for controls) (P = .66). Regarding complications other than otorrhea, the control group reported more than the CLP group (43 vs 25; ratio, 1.7:1). CONCLUSIONS AND RELEVANCE Complication rates of VT placement among patients with CLP were not higher than those among patients without CLP. Therefore, treatment with VT insertion should be administered to patients with CLP under the same guidelines as for those without CLP. Indeed, there could be an argument for a shift in practice toward more aggressive treatment of patients with CLP, who are already vulnerable to speech and social developmental delay.

The paediatric voice clinic

Background Prevalence of paediatric voice disorders has been reported as 6–9% in children of school age. The appropriate diagnosis and management of paediatric voice disorders is essential for progress in education and psychosocial development. This paper presents a review of a UK tertiary paediatric voice clinic experience of referral patterns, diagnosis, management and socioeconomic variations. Methods An audit of 195 consecutive appointments (154 were new patients) between October 2009 and September 2013 at a monthly paediatric voice clinic based at the Royal Hospital for Sick Children in Glasgow. Results Of the 154 new patients, 86 were male and 68 were female. The age at first clinic appointment shows a trimodal peak at ages 5, 8 and 11 years. General practitioners were the main referral source (46%). Vocal cord nodules accounted for 52% of diagnoses with a male predominance. Clinic attendance was most common from Scottish Index of Multiple Deprivation groups 1 (most deprived) and 5 (least deprived). Analysis of the muscle tension dysphonia group indicates that they are more likely to come from social groups 4 or 5 (69%) and an older age group (mean age 10.4 years). Discussion A dedicated paediatric voice clinic is the optimal method for assessment, diagnosis and management of these patients. Diagnosis is possible on the majority of the patients in clinic, with the predominant pathology being vocal cord nodules that receive speech and language therapy. Socioeconomic group appears to have an influence on paediatric voice particularly vocal cord nodules and muscle tension dysphonia.

Socioeconomic influence on orofacial cleft patient care.

Background Cleft lip and palate is the most common craniofacial birth defect in the UK. Orofacial clefts have functional and aesthetic implications requiring intensive multi-disciplinary follow-up to optimise development. Failure to attend follow-up is likely to have a negative impact on patient outcomes. The aim of this retrospective audit is to establish if socioeconomic status influences attendance, DNA and cancellation rates in cleft patients. Methods and results A retrospective audit of 74 orofacial cleft patients born and operated on at the Royal Hospital for Sick Children Glasgow between 2006 and 2007. There was higher rate of DNA in more deprived social groups−21% (SIMD 1) against 10% (SIMD 5). A higher rate of DNA in cleft lip and palate patients was noted. This group of patients showed a marked difference in attendance between SIMD 1 (38%) and SIMD 5 (78%). Conclusion More deprived areas have a higher outpatient DNA rate for cleft patients resulting in suboptimal follow-up. Ultimately, causation of poorer outcomes in this group is likely to be multi-factorial but the financial implication of travelling to multiple clinics should be considered and it may be that resource reallocation is the answer to address the current inequality of health care provision.

Early identification of pituitary dysfunction in congenital nasal pyriform aperture stenosis: recommendations based on experience in a single centre.

Background: Congenital nasal pyriform aperture stenosis (CNPAS) is an increasingly recognised cause of upper airway obstruction associated with midline abnormalities. Studies have described pituitary dysfunction in 40% of patients. We aimed to develop guidelines for: (a) the early identification of pituitary insufficiency to minimise surgical risk and (b) to stratify patients for follow-up. Methods: Retrospective case note review of patients with CNPAS between 2000 and 2014 in a tertiary paediatric unit. Results: 20 patients (12 female:8 male) were analysed; 16 were diagnosed during the neonatal period while 4 were diagnosed later. There was no consistent approach in the evaluation of the pituitary axis at diagnosis. Pituitary dysfunction was identified in 3 (15%) patients, 2 of whom were found during evaluation of short stature in mid-late childhood. Hypoglycaemia and conjugated hyperbilirubinaemia, but not the degree of stenosis, were highly predictive of pituitary dysfunction (p < 0.05). Available height standard deviation score (SDS) data at 1 year of 70% of our patients identified both of the late-diagnosed growth hormone-deficient patients, with SDS of -2.6 and -3.6, respectively. Conclusion: All CNPAS patients should have MRI of the brain and baseline endocrine investigations at diagnosis. Growth monitoring for at least 1 year is recommended as low, or falling, height SDS at 1 year is a good predictor of pituitary dysfunction.

Cross-sectional follow-up of voice outcomes in children who have a history of airway reconstruction surgery

This study reports vocal function in a cross‐section of children with subglottic stenosis. Each child had a history of laryngotracheal reconstruction and/or cricotracheal resection surgery. Vocal function was measured using laryngoscopy, acoustic analysis, perceptual evaluation and impact of voice on quality of life.

A systematic review of simulated laryngotracheal reconstruction animal models: Laryngotracheal Reconstruction Simulation

Review of the literature to identify practical, high‐fidelity, commercially available animal models for simulation training and surgical skills maintenance in laryngotracheal reconstruction (LTR).

Perceptual Evaluation of Voice Disorder in Children Who Have Had Laryngotracheal Reconstruction Surgery and the Relationship Between Clinician Perceptual Ratingof Voice Quality and Parent Proxy/Child Self-Report of Voice-Related Quality of Life

Reliability of the GRBAS tool for perceptual evaluation of paediatric voice disorder is measured in this study of children with a history of laryngotracheal reconstruction surgery (LTR). Additionally, the relationship between parent proxy/child self-report of voice-related quality of life with clinician perceptual rating of voice quality is analysed. Eleven children with a history of LTR provided voice recordings following the stimuli set by the CAPE-V protocol. Subjective impact of voice quality on life was measured using the paediatric voice-related quality of life questionnaire. Four trained judges rated the sound files according to both the GRBAS and CAPE-V protocol. Intra-class correlation coefficients were high for both intra-rater and inter-rater judgments across all parameters of the GRBAS protocol, and a strong correlation was found between the grade rating of the GRBAS and the overall severity rating of the CAPE-V. Some elements of parent proxy reporting of voice-related quality of life were significantly negatively correlated with clinician perceptual rating of voice quality, while there was no significant relationship between child self-report and clinician perceptual rating.

Classification of first branchial cleft anomalies: is it clinically relevant?

Background There are three classification systems for first branchial cleft anomalies currently in use. The Arnot, Work and Olsen classifications describe these lesions on the basis of morphology, tissue of origin and clinical appearance. However, the clinical relevance of these classifications is debated, as they may not be readily applicable in all cases and may provide no additional information on how the lesion should be managed. Objective We seek to investigate this issue by applying these classification systems to cases from our centre and evaluating the information gained. Patients and methods A retrospective case note review of all first branchial cleft anomalies excised at our institution between 2004 and 2014 was carried out, recording patient demographics, information on the anomalies and how they were investigated and managed. Results This search identified eight unilateral cases and one bilateral case of first branchial cleft anomalies. These were a heterogenous group of lesions, which were variably investigated and managed. Categorization of these cases into Arnot, Work and Olsen subtypes did not correlate with the lesion’s relation with the facial nerve or the outcome of excision. Conclusion The current classification systems used for first branchial cleft anomalies have little clinical relevance apart from providing extensive descriptions to aid in diagnosis. We advise instead that clinicians use imaging techniques to gain as much information as possible about these lesions before excision and be aware of the risk to the facial nerve at the time of excision. A description of the lesion’s relation with the facial nerve at the time of excision may provide more information on the likely outcomes compared with the classifications currently in use.