Raymond C. Maguire

Injection Laryngoplasty for Type 1 Laryngeal Cleft in Children

Objective. To review the 2-year, single-institution experience with injection laryngoplasty for diagnosis and treatment of type 1 laryngeal clefts (LC-1). Study Design. Case series with chart review. Setting. Tertiary care academic children’s hospital. Subjects and Methods. Patients at our institution who underwent injection laryngoplasty for LC-1 from January 2008 to December 2009. Outcome measures included patient demographics, surgical and anesthetic technique, effect on swallowing, and complications. Preoperative and postoperative swallowing evaluations were compared, and quality and duration of effects were calculated. Results. Sixteen children, 9 male and 7 female, underwent injection laryngoplasty for LC-1. Mean gestational age was 36.4 weeks (SD, 4.0 weeks; range, 27-41 weeks). Six patients had a major congenital anomaly (37.5%). Mean age at injection was 11.8 months (SD, 8.9 months; range, 2.9-33.5 months). Nine patients (56%) demonstrated complete resolution of penetration and aspiration on postoperative modified barium swallow (MBS), 4 patients (25%) had some improvement, and 3 patients (19%) showed no change. There were no complications. Mean duration of symptom improvement was 3.3 months (SD, 3.0 months; range, 0-11 months). Five patients went on to have definitive surgical LC-1 repair. Conclusion. Injection laryngoplasty was found to have favorable results in this group of patients with LC-1. Most patients experienced complete resolution of aspiration on MBS, and no patients experienced complications. These findings support the further study of injection laryngoplasty for LC-1 as both a diagnostic and therapeutic technique. Longer follow-up intervals are necessary to elucidate the predictive value with regard to success of formal cleft repair.

Injection Medialization Laryngoplasty in Children

OBJECTIVE To review our experience with vocal fold injection medialization in children. DESIGN Retrospective case series. SETTING Tertiary care academic childrens hospital. PATIENTS All pediatric patients at our institution who underwent injection laryngoplasty for vocal fold medialization from 2003 to 2009. MAIN OUTCOME MEASURES Age, sex, indication for injection, injection material, surgical and anesthetic technique, outcomes including effect on voice and swallowing, and complications. RESULTS Thirteen patients underwent 27 injections. Mean patient age was 8.0 years (range, 1.3-18.0 years). The causes of glottic insufficiency included prolonged intubation (6 patients, 46%), patent ductus arteriosus ligation (2 patients, 15%), other cardiac surgery (2 patients, 15%), neck surgery or trauma (2 patients, 15%), and postviral status (1 patient, 8%). Eight patients had vocal fold paralysis or paresis; 3 had vocal fold atrophy; and 2 had vocal fold scarring. Indications for surgery included hoarseness (11 patients), aspiration (5 patients), and dysphagia without aspiration (1 patient). Materials injected included Gelfoam (n = 13), Radiesse Voice (n = 10), and Radiesse Voice Gel (n = 4). The average number of injections per patient was 2.1 (range, 1-9). Patients experienced improvement in symptoms (subjective or objective) after injection in 24 of 27 cases (89%); 15 of 16 injections in patients with hoarseness led to improvement (94%); and 11 of 13 injections in patients with dysphagia or aspiration led to improvement (85%). One patient experienced 2 days of inspiratory stridor postoperatively, which resolved spontaneously. There were no other complications. CONCLUSIONS This study supports injection laryngoplasty as a safe and effective intervention for children with glottic insufficiency. Further prospective studies are necessary to confirm these findings.

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.

Role of polysomnography in the development of an algorithm for planning tracheostomy decannulation.

Objective To examine the role of polysomnography (PSG) in helping determine readiness of tracheostomized patients for decannulation. Study Design Case series with chart review of pediatric patients who underwent PSG with tracheostomy tube in place with the goal of decannulation. Setting Tertiary care pediatric center. Subjects and Methods Twenty-eight tracheostomized patients who underwent PSG from January 2006 to March 2012 were included. Outcome measures were successful decannulation, PSG results, surgical procedures, and medical comorbidities. Results Of the 28 patients, 20 (71.4%) were decannulated and 8 (28.6%) were not. One (3.6%) patient failed long-term decannulation. The average apnea-hypopnea index (AHI) with a capped tracheostomy for those successfully decannulated was 2.75 (range, 0.6-7.6), while the AHI for those not decannulated was 15.99 (range, 3.2-62). Factors associated with success or failure to decannulate were assessed, and an algorithm was developed to plan for successful decannulation. Laryngotracheal reconstruction was a significant factor in those successfully decannulated. Those who were not decannulated had multiple medical comorbidities, multilevel airway obstruction, need for additional surgery, or chronic need for pulmonary toilet. Conclusions Polysomnography may be a useful adjunctive study in the process of determining a patient’s readiness for decannulation. Our current algorithm for decannulation includes upper airway endoscopy with identification of levels of obstruction, followed by surgical correction of those obstructions; capped PSG to determine patency of the airway and help assess lung function; and overnight intensive care unit admission for capping trial, with decannulation the following day if well tolerated.

Endoscopic anterior cricoid split with balloon dilation in infants with failed extubation

Subglottic injury (SGI) is a known complication of prolonged intubation in neonates and infants and can lead to failed extubation. SGI is a spectrum that includes mucosal edema, ulceration, granulation perichondritis, and mature scar formation. Although medical management aimed at treating mucosal edema and extraesophageal reflux is successful in treating a majority of patients, some require surgical intervention to successfully achieve extubation. The surgical options for these patients include tracheostomy, open anterior cricoid split (ACS), and laryngotracheal reconstruction with cartilage grafting. Open ACS is performed through an external incision requiring placement of a drain for a few days. Extubation success rates in the 70% to 80% range have been widely reported. In this article we describe an endoscopic technique for ACS, in which after an endoscopic airway assessment confirms isolated SGI, the cricoid cartilage is divided transluminally with cold steel. Balloon dilation (BD) is then performed with an appropriately sized angiography balloon. We describe preliminary results in which two of three patients were successfully extubated after endoscopic ACS with BD. We believe that this novel technique is a promising alternative to open ACS with similar indications. In addition to the avoidance of a skin incision, endoscopic ACS with BD may enable extubation with comparably shorter lengths of postprocedure intubation than open ACS. Larger series will be required to further establish outcomes of this procedure, including success and complication rates.

Objective endoscopic findings in patients with recurrent croup: 10-year retrospective analysis

OBJECTIVE (1) To determine the incidence and severity of subglottic stenosis on endoscopic evaluation in a pediatric population of patients with recurrent croup. (2) To determine the incidence of abnormal findings on bronchoalveolar lavage and esophageal biopsy in a pediatric population with recurrent croup. METHODS Case series with historical chart review of clinical data for pediatric patients (age ≤18 years) at a tertiary care childrens hospital who underwent endoscopic evaluation of the upper aerodigestive tract with a diagnosis of recurrent croup over a ten-year period (2002-2012). Subglottic stenosis was graded on Myer-Cotton scale. Lipid-laden macrophages on bronchoalveolar lavage were noted as none/small/moderate/large with evidence of reflux noted as moderate or large. Esophageal biopsy specimens were evaluated for evidence of esophagitis. Data is expressed as mean±SEM. RESULTS 1825 charts were reviewed of which 197 met inclusion criteria. Mean age at endoscopy was 53±3 months. Subglottic stenosis was noted in 41 patients (20.8%) with 95.1% being mild or Grade I. Abnormal findings on bronchoalveolar lavage were noted on 9.5% of bronchoalveolar lavage specimens. Abnormal esophageal biopsies were noted on 19.9% of specimens. Esophagitis was noted on 8.8% of biopsy specimens. CONCLUSIONS Subglottic stenosis is a risk factor for recurrent croup. Evidence suggestive of reflux may be noted on bronchoalveolar lavage or esophageal biopsy, but these findings may not correlate with subglottic stenosis in recurrent croup patients.

Aortopexy for Innominate Artery Tracheal Compression in Children

Objectives (1) Evaluate the presentation, diagnostic workup, and outcomes of contemporary surgical intervention for airway obstruction from innominate artery tracheal compression in children. (2) Assess the significance of synchronous airway lesions in the treatment of innominate artery tracheal compression. Study Design Case series with chart review. Setting Tertiary care children’s hospital. Methods This study is a retrospective medical record review of 26 consecutive children who underwent aortopexy for innominate artery tracheal compression at a tertiary care children’s hospital. Presenting symptoms, diagnostic workup, presence of synchronous airway lesions, length of hospitalization, and treatment outcomes were examined. Results Twenty-six patients (17 male, 65%) were included in the study. All were diagnosed with bronchoscopy and confirmed with radiographic imaging. Median age at diagnosis and surgery was 9.7 and 10.0 months, respectively. Presenting symptoms included noisy breathing (93%), cough (78%), dyspnea (44%), apnea (44%), cyanosis (19%), and recurrent respiratory infections (15%). Average degree of tracheal compression was 71% (SD, 12%). Fifteen of 26 (58%) patients had synchronous airway lesions, including mild laryngomalacia and subglottic stenosis. Median length of stay was 2 days. Median follow-up was 10 months. Subjective improvement occurred in all 21 patients for whom follow-up information was available. Conclusion Anterior tracheal vascular compression can cause a variety of airway symptoms. Mild synchronous airway lesions are common and do not prevent successful aortopexy. Aortopexy is a viable treatment option for symptomatic anterior tracheal vascular compression from the innominate artery.

Aortopexy for Vascular Tracheal Compression in Children

Objective: 1) Evaluate the presentation, diagnostic workup, and outcomes of contemporary surgical intervention for airway obstruction from innominate artery tracheal compression in children. 2) Assess the significance of synchronous airway lesions in the treatment of innominate artery tracheal compression. Method: This study is a retrospective medical record review of 26 consecutive children who underwent aortopexy for innominate artery tracheal compression at a tertiary-care children’s hospital. Presenting symptoms, diagnostic workup, presence of synchronous airway lesions, length of hospitalization, and treatment outcomes were examined. Results: Twenty-six patients (17 male, 65%) were included in the study. All were diagnosed with bronchoscopy and confirmed with radiographic imaging. Median age at diagnosis and surgery was 9.7 and 10.1 months, respectively. Presenting symptoms included noisy breathing (93%), cough (78%), dyspnea (44%), apnea (44%), cyanosis (19%), and recurrent respiratory infections (15%). Average degree of tracheal compression was 71% (SD 12%). Fifteen of 26 (58%) patients had synchronous airway lesions, including mild laryngomalacia and subglottic stenosis. Median length of stay was 2 days. Median follow-up was 10 months. Subjective improvement occurred in all 20 patients for whom follow-up information was available. Conclusion: Anterior tracheal vascular compression can cause a variety of airway symptoms. Mild synchronous airway lesions are common and do not prevent successful aortopexy. Aortopexy is a safe and effective treatment for symptomatic anterior tracheal vascular compression from the innominate artery.