Hamdy El-Hakim

Unilateral Vocal Cord Paralysis Following Patent Ductus Arteriosus Ligation in Extremely Low-Birth-Weight Infants

OBJECTIVE To determine if unilateral vocal cord paralysis (UVCP) following patent ductus arteriosus (PDA) ligation is associated with respiratory and swallowing morbidities in extremely low-birth-weight (ELBW) infants. DESIGN Case-control study. SETTING Tertiary care neonatal intensive care units and pediatric hospital. PARTICIPANTS Twenty-three infants undergoing PDA ligation (subdivided into the main study group of 12 infants with UVCP and 11 without paralysis) and 12 weight- and gestational age-matched ELBW controls. MAIN OUTCOME MEASURES Incidence of UVCP, time requiring supplemental oxygen and ventilatory support, length of hospital stay, incidence and duration of tube feeding following discharge, and incidence of chronic lung disease. RESULTS The overall incidence of UVCP was 52% (12/23), increasing to 67% (12/18) in ELBW infants. Infants without UVCP following PDA ligation were heavier (P = .006), with a more advanced gestational age (P = .03). Patients with UVCP required longer tube feeding (relative risk, 8.25; 95% confidence interval, 1.93-46.98; P = .003), supplemental oxygen (P = .004), and ventilatory support (P = .001) and had a longer hospital stay (P < .001). In comparison to matched controls, infants with UVCP required longer tube feeding (relative risk, 9.00; 95% confidence interval, 2.08-51.30; P = .003), supplemental oxygen (P = .03), and ventilatory support (P = .002) and had a longer hospital stay (P < .001). CONCLUSIONS There was a high incidence of occurrence of UVCP (67%) associated with PDA ligation in ELBW infants. Unilateral vocal cord paralysis following PDA ligation does seem to be associated with increased requirements for tube feeding, respiratory support, and hospital stay in these ELBW infants.

Influence of age at implantation and of residual hearing on speech outcome measures after cochlear implantation: binary partitioning analysis.

The goal of this study was to evaluate speech understanding outcomes in prelingually deaf children who use a cochlear implant device. Specifically, we discuss investigations on 2 prognostic variables — age at implantation and degree of residual hearing — and use a novel method: binary partitioning analysis. Our outcome measures are standard speech perception evaluations, including the Word Intelligibility by Picture Identification (WIPI) test, the Phonetically Balanced–Kindergarten (PBK) test, and the Glendonald Auditory Screening Procedure (GASP). Regarding age at implantation, we definitely showed that growth rates of speech understanding do relate to age at implantation, but not in a simple fashion. We used binary partitioning in an attempt to find the age at implantation that best separates the performances of children with younger versus older ages at implantation. We found that there is no one “critical age”; much appears to depend on the nature and difficulty (eg, whether open- or closed-set) of the test used. Regarding residual hearing, binary partitioning analysis was unable to show that the amount of residual hearing (as shown by preimplantation audiometric data) has any significant bearing on speech outcome measures in congenitally or prelingually deaf children.

The Natural History of Vincristine-Induced Laryngeal Paralysis in Children

OBJECTIVE To outline the natural history of vincristine-induced laryngeal paralysis (VLP) in children. DESIGN Retrospective case series and review of reported cases in the English-language literature. SETTING Tertiary pediatric center. PATIENTS The study included all children with a confirmed diagnosis of VLP by inspection and with complete clinical information. The sources for patient identification were a prospectively kept database and a review of the English-language literature, conducted on PubMed since 1966, as well as a bibliography search. MAIN OUTCOME MEASURES Charts and literature were reviewed for demographics, primary diagnosis, other diagnoses, and duration and method of treatment. The prevalence of VLP, locally, was also calculated. RESULTS Four children (3 boys and 1 girl) were identified in our database over a 5(1/2)-year period, and 10 children (1 girl, 8 boys, and 1 with sex omitted) were described in the English-language literature. Four children had unilateral vocal fold paralysis only, all left-sided. The median age was 2.6 years. Acute lymphoblastic leukemia was the underlying diagnosis in 8 patients. Two patients had Down syndrome, and 1 patient had Charcot-Marie-Tooth disease, type 1. Only 2 patients required tracheotomies, and 1 patient was treated temporarily with bilevel positive-pressure ventilation. The median duration of paralysis was 6.8 weeks. The prevalence of VLP was 1.36%. CONCLUSIONS The data suggest that VLP is probably underreported and possibly underdiagnosed. Endoscopic inspection is a must in all patients with airway symptoms who are receiving vincristine therapy. Early recognition of VLP is mandatory, as it is reversible, has a good prognosis, and usually needs only interruption of vincristine therapy and conservative treatment.

Injection Augmentation of Type 1 Laryngeal Clefts

Objective. To describe a series of children diagnosed with type I congenital laryngeal clefts (LC-I) and treated, due to various presentations, with endoscopic injection augmentation (IA). Study Design. Case series with chart review. Setting. Tertiary care academic children’s hospital in Edmonton, Canada. Subjects. All pediatric patients diagnosed with LC-I and treated with IA in a single tertiary care practice. Methods. The children were identified from a prospectively collected database. Only those who were treated with IA and had a minimum follow-up of 3 months were included. The authors collected demographics, diagnoses, surgical procedures, number of IA procedures, clinical outcomes, and complications. Results. Over a period of 8 years, 43 patients were diagnosed with LC-I. Eighteen had undergone IA over the past 4 years. Mean age at IA was 37.11 ± 32.68 months with a male-to-female ratio of 1.25:1. The indications were swallowing dysfunction (13), atypical croup (2), chronic cough (1), cyanotic spells (1), and asthma (1). Seven patients required repeated injections (mean, 2.57 injections). A total of 13 patients responded with resolution of symptoms in question. A single postoperative complication was recorded. Conclusion. IA is a brief, simple management option that succeeds in a number of children with LC-I. It is minimally morbid and supplements other conservative approaches to treat the condition.

Atypical Croup Association with Airway Lesions, Atopy, and Esophagitis

Objective To report on airway endoscopic findings and gastrointestinal and atopic conditions in a large consecutive series of atypical croup. Study Design Case series with chart review. Setting Tertiary pediatric referral center. Subjects and Methods A surgical database was searched for all children who underwent full airway endoscopy to investigate atypical croup. The primary outcome measure was the prevalence of large airway lesions in patients with atypical croup undergoing endoscopy. Demographics, secondary diagnoses, and rate of positive findings were documented. Age and atopy were correlated using Spearman’s correlation coefficient, and multivariate analysis identified predictors of large airway lesions. Results Eighty patients were identified over a period of 8 years (58 boys; mean [SD] age 4.8 [3.8] years; range, 46 days to 13.7 years). Of the 80 children, 31 had positive airway findings, with 33 large airway lesions demonstrated, including 10 subglottic stenosis, 7 laryngeal clefts, 6 subglottic hemangiomas, 4 tracheomalacia, and 3 laryngomalacia. Esophagitis was diagnosed in 36 children, 5 of whom had eosinophilic esophagitis. Thirty-five children had an atopic condition including asthma, allergic rhinitis, eosinophilic esophagitis, and food allergies. Age correlated with associated atopy (coefficient 0.4, P < .0001) and predicted the presence of any airway lesion (coefficient −0.0625, P < .001) and subglottic stenosis in particular (coefficient −0.0362, P = .001). Prior intubation predicted subglottic stenosis (coefficient 0.267, P = .011). Conclusion Thirty-nine percent of airway endoscopies demonstrated large airway lesions. When eosinophilic esophagitis was sought, it was confirmed in over 1:10 patients. The findings bolster the case for airway endoscopy coupled with allergy and gastrointestinal investigations.

Secondary airway lesions in laryngomalacia: a different perspective.

Objective. To document the prevalence of secondary airway lesions (SALs) among children with laryngomalacia (LM). Study Design. A cross-sectional observational study. Setting. Single practice in a tertiary care pediatric facility. Subjects and Methods. Patients diagnosed with LM were initially identified from a prospectively kept surgical database. Patients with cardiac/large-vessel malformations, prematurity, repeated or prolonged intubations, acute infections, or prior airway surgery were excluded. Only children who had a full examination of the airway were included. Other associated diagnoses along with demographics, surgical intervention, and type of LM were included. Results. Over an 8-year period, 1112 patients underwent laryngoscopy and bronchoscopy. A total of 108 consecutive cases were diagnosed with LM (78 primary diagnosis and 30 secondary diagnosis). After excluding 17 with disorders associated with large airway disease, 91 LM patients were included. The mean age was 553.23 days (ranging between 5 days and 15 years); 60 were boys and 31 were girls. The prevalence of SALs was 7.7% (95% confidence interval, 7.65-7.76; 7 children; 4 subglottic stenosis, 4 tracheomalacia, 1 bronchomalacia, and 1 choanal atresia). Fifty-nine patients underwent supraglottoplasties, while 1 patient had a tracheostomy. Conclusions. After accounting for conditions known to be associated with large airway lesions, the prevalence of SALs associated with laryngomalacia was much less than previously reported. The authors hypothesize that the upper-end figures are a reflection of highly select cohorts and the inclusion of patients with other pathology known to be associated with subglottic stenosis, tracheomalacia, and bronchomalacia and low thresholds for diagnosing mild subglottic stenosis.

The accuracy of diagnostic tests for adenoid hypertrophy: A systematic review

BACKGROUND Adenoid hypertrophy may cause sleep-disordered breathing and altered craniofacial growth. The authors conducted a study to gauge the accuracy of alternative tests compared with nasoendoscopy (reference standard) for screening adenoid hypertrophy. METHODS The authors conducted a systematic review that included searches of electronic databases, hand searches of bibliographies of relevant articles and gray literature searches. They included all articles in which an alternative test was compared with nasoendoscopy in children with suspected nasal or nasopharyngeal airway obstruction. RESULTS The authors identified seven articles that were of poor to good quality. They identified the following alternative tests: multirow detector computed tomography (sensitivity, 92 percent; specificity, 97 percent), videofluoroscopy (sensitivity, 100 percent; specificity, 90 percent), rhinomanometry with decongestant (sensitivity, 83 percent; specificity, 83 percent) and clinical examination (sensitivity, 22 percent; specificity, 88 percent). Lateral cephalograms tended to have good to fair sensitivity (typically 61-75 percent) and poor specificity (41-55 percent) when adenoid size was evaluated but excellent to good specificity when airway patency was evaluated (68-96 percent). CONCLUSIONS No ideal tool exists for dentists to screen adenoid hypertrophy, owing to access constraints, radiation concerns and suboptimal diagnostic accuracy. Research is needed to identify a low-risk, easily acceptable, highly valid diagnostic screening tool. PRACTICAL IMPLICATIONS Although lateral cephalograms (which have good to fair sensitivity) and a thorough medical history (which has good specificity) are imperfect individually, when they are used together, they can compensate for each others weaknesses. This combined approach is the best tool available to dentists for screening adenoid hypertrophy.

Major Salivary Duct Clipping for Control Problems in Developmentally Challenged Children

OBJECTIVES To introduce a technical modification for interruption of the parotid and submandibular salivary ducts and to demonstrate the techniques effectiveness and effect on quality of life. DESIGN Retrospective, uncontrolled, consecutive case series. SETTING A tertiary care pediatric otolaryngology practice. PATIENTS Eighteen drooling and aspirating children. INTERVENTION Transoral interruption of parotid and submandibular ducts using vascular clips. MAIN OUTCOME MEASURES Manifestations of poor saliva control (visible drooling, number of shirts and bibs used, choking episodes, embarrassment, and incidence of salivary aspiration), Glasgow Childrens Benefit Inventory scores (possible score range, - 100 to + 100), and complications. RESULTS Eighteen patients (10 boys and 8 girls) were treated in 14 months. Patient age ranged from 2 to 14 years. Follow-up ranged from 3 to 18 months. No complications occurred. Nine patients had no drooling at all after surgery. There was a significant reduction in the number of bibs and shirts used (P < .001). Regarding measures indicating circumoral skin problems, embarrassment, choking episodes, and aspiration pneumonia, all the patients had significant improvements after surgery. The mean Glasgow Childrens Benefit Inventory score was 33.2. CONCLUSIONS Salivary duct clipping is an efficient and safe method of controlling saliva in neurologically challenged children. The operation positively affects the childrens quality of life.

Acquired bilateral adductor laryngeal paralysis in neonates and children: A case series and a systematic review

OBJECTIVES To present a series of acquired bilateral adductor laryngeal paralysis (BAdLP) and review the literature on clinical manifestations and management. METHODS A retrospective review of a single tertiary care practice of pediatric otolaryngology was conducted. Patients were identified from a surgical database spanning twelve years of practice (2002-2013). The variables documented included gender, age at presentation, co-morbid conditions, documented laryngeal findings on endoscopy, management and outcome. A systematic review of the literature was conducted to identify reports on BAdLP in children and associated conditions. RESULTS Five cases (four girls and one boy) ranging from 3 months to 16 years of age were identified. All cases were documented using rigid and/or flexible laryngoscopy. In four cases, the onset was after major cardiac surgery complicated by cerebral vascular accidents, while one followed a thalamic stroke. Four were managed with tube feeding. Only three papers reported BAdLP in children. CONCLUSIONS The cases identified were all acquired after a central neurological insult. The profile is distinct from the congenital adductor form of laryngeal paralysis previously described. However, the symptom complex is identical. We believe this is the largest case series from one center to be reported.

Injection Augmentation for Type I Laryngeal Clefts

Objective: Describe a series of children diagnosed with type I congenital laryngeal clefts (LC-I) and treated due to various presentations with endoscopic injection augmentation (IA). Method: This is a retrospective study. The children were identified from a prospectively collected database. Only those who were treated with IA (using hyaluronic acid derivatives) and had a minimum follow-up of 3-months were included. We collected demographics, diagnoses, surgical procedures, number of IA, clinical outcomes, and complications. Results: Over a period of 8 years, 32 patients were diagnosed with LC-I. Fifteen had undergone IA over the past 3 years. Mean age at IA was 28.67 ± 17.54 months with a male-to-female ratio of 8:7. The indications were swallowing dysfunction (13) and atypical croup (2). Seven patients required repeated injections (mean of 2.57 injections). A total of 10 patients responded with resolution of symptoms in question. No record of complications was found. Conclusion: IA is a brief, simple management option that succeeds in a number of children with LC-I. It is minimally morbid and supplements other conservative approaches to treat the condition.