Karen B. Zur

Pediatric airway foreign body retrieval: surgical and anesthetic perspectives

Airway foreign body aspiration most commonly occurs in young children and is associated with a high rate of airway distress, morbidity, and mortality. The presenting symptoms of foreign body aspiration range from none to severe airway obstruction, and may often be innocuous and nonspecific. In the absence of a choking or aspiration event, the diagnosis may be delayed for weeks to months and contribute to worsening lung disease. Radiography and high resolution CT scan may contribute to the eventual diagnosis. Bronchoscopy is used to confirm the diagnosis and retrieve the object. The safest method of removing an airway foreign body is by utilizing general anesthesia. Communication between anesthesiologist and surgeon is essential for optimal outcome. The choice between maintenance of spontaneous and controlled ventilation is often based on personal preference and does not appear to affect the outcome of the procedure. Complications are related to the actual obstruction and to the retrieval of the impacted object. The localized inflammation and irritation that result from the impacted object can lead to bronchitis, tracheitis, atelectasis, and pneumonia.

Multimodality Education for Airway Endoscopy Skill Development

Objectives: Airway endoscopy is a difficult skill to master. A unique practicum was designed to help otolaryngology residents develop endoscopy skills. The learning modalities included lectures, an animal laboratory, high-fidelity manikins, virtual bronchoscopy simulation, and standardized patients. This study compares the relative subjective value of these learning modalities for skill development and realism. Methods: Participants used a Likert scale (1 = disagree to 5 = agree) and open responses to anonymously rate the efficacy of 5 learning modalities for teaching airway management, endoscopy skills, and clinical leadership and for providing a realistic experience. Results: The results in 2007 were uniformly positive, with mean scores for every category and modality greater than 4 for developing cognitive, psychomotor, and affective skills; managing normal and abnormal conditions; preventing and managing complications; improving endoscopy skills; understanding team process; and experiencing overall and manual “feel” realism. In 2008, the participants were encouraged to more critically evaluate the course. The ratings demonstrated statistically significant differences between the mean scores for 4 of the 9 evaluation categories in 2007 and all 9 categories in 2008. Conclusions: Specific learning modalities (eg, lecture, animal laboratory, high-fidelity manikin, virtual bronchoscopy, standardized patient) were perceived to have different values for teaching airway management, developing endoscopy skills, teaching clinical leadership, and providing a realistic experience. We propose that these learning modalities can be used in a complementary manner.

Evolving treatments in the management of laryngotracheal hemangiomas: Will propranolol supplant steroids and surgery?

There has been a dramatic evolution in the treatment of laryngotracheal hemangiomas during the past decade and recent accounts and case reports of propranolol treatment have been encouraging. The purpose of the study is to determine the clinical course and outcomes of treating laryngotracheal hemangiomas at The Childrens Hospital of Philadelphia in the last 8 years with the various modalities. We review with contemporary surgical techniques, including propranolol, and determine the results, limitations and complications. The study was a retrospective review of all patients referred to the Otolaryngology service at The Childrens Hospital of Philadelphia with symptomatic laryngotracheal hemangiomas between January 2002 and December 2010. The study consisted of 30 infants, ranging in age from 1 to 18 months at time of diagnosis. Surgical interventions included open surgical excision, laser surgery, microdebrider excision and/or propranolol therapy. The main outcome measures include improvement in symptoms, decannulation, number of required treatments and airway size. All but two patients underwent an initial trial of steroids. Thirteen patients underwent open surgical excision, 9 requiring cartilage grafts and 12 were done in a single stage. Twelve surgical patients remained asymptomatic. One patient with diffuse mediastinal disease experiencing postoperative airway symptoms despite a normal appearing airway improved on propranolol. Two patients underwent at least 2 laser ablations, 4 responded to systemic steroids alone, and 1 had microdebrider resection. In the last 14 months, 12 patients have had propranolol therapy at a dose of 2mg/kg divided every 8h. Eight patients improved clinically within 1 week of initiating treatment. Four patients failed to respond to propranolol therapy; 1 patient subsequently underwent open excision and the other continued with a tracheostomy for 18 months and finally was decannulated. A third patient had a partial response, but remains relatively asymptomatic. A fourth patient has had no response at all. There were no major complications from propranolol; minor complications included diarrhea and decreased appetite. This study gives an overview of the evolution of hemangioma treatment at our institution over the last 8 years. Surgical excision remains an effective treatment for subglottic hemangiomas. Carefully administered, propranolol may demonstrate efficacy as a first-line agent in most cases avoiding surgery, tracheostomy, prolonged steroids, or as treatment of diffuse and unresectable disease. However, some lesions may be resistant to propranolol and require surgery or long-term steroids.

Single- vs Double-Stage Laryngotracheal Reconstruction

OBJECTIVE To compare single-stage laryngotracheal reconstruction (ssLTR) and double-stage LTR (dsLTR). DESIGN Retrospective medical record review. SETTING Tertiary care childrens hospital. PATIENTS Seventy-one patients underwent 84 procedures (22 ssLTRs and 62 dsLTRs). INTERVENTION Review of preoperative disease severity and surgical outcomes for patients who underwent ssLTR vs dsLTR. MAIN OUTCOME MEASURE Operation-specific and overall decannulation rates. RESULTS Regarding ssLTRs, the mean grade of subglottic stenosis was 2.1 and the overall and operation-specific decannulation rates were 100% and 91%, respectively. The mean grade of subglottic stenosis for double-stage procedures was 2.9, and the overall and operation-specific decannulation rates were 93% and 68%, respectively. Patients who underwent ssLTR and dsLTR were further divided into early and late groups based on whether the posterior graft was sutured in place (early) or not (late). Overall and operation-specific decannulation rates were 100% and 89%, respectively, for the early single-stage group and 100% and 92% for the late group. Regarding the dsLTR group, overall and operation-specific decannulation rates were 88% and 42%, respectively, for the early group and 95% and 79% for the late group. Among all groups, there was no significant difference in overall decannulation rates (P > .05). Single-stage LTR offered an increased rate of operation-specific decannulation over dsLTR (P < .05). However, that difference was not significant between the late ssLTR and the late dsLTR groups (P > .05). CONCLUSION Careful assessment of preoperative disease severity and overall medical status will help surgeons choose between ssLTR and dsLTR, maximizing patient outcomes for both modalities.

Otolaryngologists may not be doing enough to diagnose pediatric eosinophilic esophagitis

OBJECTIVE To systematically evaluate the diagnosis of eosinophilic esophagitis (EE). METHODS A retrospective review of 657 patients seen at the EE center of a tertiary care childrens hospital between 1994 and 2007 was performed. Charts were reviewed for the 144 patients who were also seen by the otolaryngology service. RESULTS One hundred forty-four patients received 193 otolaryngology-related diagnoses. Eustachian tube dysfunction (27.5%) and sleep disordered breathing (24.9%) were the most common, followed by dysphagia (13.0%), rhinosinusitis/nasal congestion (9.3%) and airway stenosis (5.2%). Seventy-nine patients (54.9%) had a pre-existing diagnosis of EE at the time of their otolaryngology consultation. Twenty-one patients (14.6%) were referred to the gastroenterology service for evaluation for EE. Forty-four patients (30.5%) remained undiagnosed. Twenty-five of these patients presented with dysphagia, 16 of whom were not previously diagnosed with EE; only 4 of these 16 patients were referred for evaluation for EE. In one case, a child with moderate sized tonsils underwent adenotonsillectomy for dysphagia and failure to thrive; this patient was diagnosed with EE 1 month post-operatively. CONCLUSIONS Twenty percent of patients with EE may require care by an otolaryngologist for a myriad of complaints. Even experienced pediatric otolaryngologists may not recognize this condition. Otolaryngologists should consider EE in patients presenting with dysphagia. A careful gastroenterology review of symptoms may also allow otolaryngologists to identify EE in patients with allergy mediated nasal complaints, or laryngeal/airway disorders.

Multidisciplinary approach to vocal cord dysfunction diagnosis and treatment in one session: A single institutional outcome study

OBJECTIVE To determine whether the multidisciplinary approach to the management of vocal cord dysfunction (VCD), which combines patient education and behavioral intervention in the same session that VCD is diagnosed, provides long-term therapeutic benefits. METHODS Chart review and telephone interviews of patients treated for VCD at The Childrens Hospital of Philadelphia were performed in this retrospective nonrandomized study. All forty patients diagnosed with VCD from October 2007 to April 2009 were included. Patients were evaluated with a multidisciplinary team approach, including speech therapy assessment, otolaryngology exam and flexible laryngoscopy. Patients with VCD were educated about their condition and instructed about breathing techniques in the same session. RESULTS Twenty-two patients were available for a phone interview. Mean age of patients was 13.4 ± 3.0 years. Sixteen patients were female. Mean number of clinic visits was 1.3 ± 0.8. Average time between phone interview and first clinical encounter was 14.0 ± 7.2 months. Compliance rate to demonstrate breathing exercises was 90.9%. Nineteen out of 22 patients (86.4%) reported improvement of their symptoms in frequency and/or severity. Six patients (27.3%) sought additional medical advice related to their respiratory symptoms. Twenty-one patients (95.5%) were able to maintain or increase their level of physical activity following clinic visit. CONCLUSION Combining the diagnostic encounter with multidisciplinary behavioral intervention in a single visit is an efficacious approach for the long-term management of VCD in the pediatric population.

Laryngotracheal reconstruction with posterior costal cartilage grafts: Outcomes at a single institution

Objective: To describe our outcomes after laryngotracheal reconstruction that required posterior costal cartilage grafting focused on decannulation rates and complications. Study Design: Case series with chart review. Subjects and Methods: Charts were reviewed on 58 patients. Operation specific and overall decannulation rates were determined. Complications were reviewed and correlated with technique of graft placement. Available voice outcomes were reviewed. Results: Forty-eight patients were included. There was no statistically significant correlation between degree of stenosis and rate of decannulation. The overall decannulation rate, regardless of number of surgeries performed, was 96 percent. The relative risk for complications was higher among children who had a sutured versus a sutureless flanged posterior graft (RR = 2.5, P < 0.01). The most common voice anomaly was supraglottic compression. Conclusions: Operation-specific decannulation rates are not significantly different with increasing disease severity, although the power to detect small differences in this study is low. Sutureless graft placement is associated with a lower complication rate. Supraglottic compression is a common postoperative compensatory vocal behavior and may correlate with disease severity.

Laryngotracheal reconstruction with resorbable microplate buttressing

In patients undergoing laryngotracheal reconstruction (LTR), malacic segments of trachea can pose challenges to successful reconstruction. Malacic segments may inadequately support cartilage grafts used in augmentation surgery, sometimes requiring cricotracheal or tracheal resections. We describe a novel technique of LTR with resorbable microplate buttressing of malacic lateral tracheal segments.

International Pediatric ORL Group (IPOG) laryngomalacia consensus recommendations.

OBJECTIVE To provide recommendations for the comprehensive management of young infants who present with signs or symptoms concerning for laryngomalacia. METHODS Expert opinion by the members of the International Pediatric Otolaryngology Group (IPOG). RESULTS Consensus recommendations include initial care and triage recommendations for health care providers who commonly evaluate young infants with noisy breathing. The consensus statement also provides comprehensive care recommendations for otolaryngologists who manage young infants with laryngomalacia including: evaluation and treatment considerations for commonly debated issues in laryngomalacia, initial work-up of infants presenting with inspiratory stridor, treatment recommendations based on disease severity, management of the infant with feeding difficulties, post-surgical treatment management recommendations, and suggestions for acid suppression therapy. CONCLUSION Laryngomalacia care consensus recommendations are aimed at improving patient-centered care in infants with laryngomalacia.

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

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.