Objectives/Hypothesis
To critically review current literature comparing interventional approaches for unilateral vocal fold paralysis.
Study Design
Systematic review of the literature.
Methods
All ...English‐language literature published in the PubMed database was eligible for inclusion. Inclusion criteria were: 1) the major topic must be a direct comparison of outcomes in interventions for unilateral vocal fold paralysis, 2) the subjects were 18 years or older, and 3) it was original research. Studies involving treatment of bilateral vocal fold paralysis and nonprocedural interventions were excluded. Included studies were categorized according to level of evidence. Outcomes analyzed were acoustic and aerodynamic measures, auditory perceptive evaluation, laryngoscopic findings, and complications.
Results
Of the 504 studies retrieved from the search strategy, 17 studies met inclusion and exclusion criteria. Overall, four interventional approaches were used for treatment of unilateral vocal fold paralysis: medialization thyroplasty, injection laryngoplasty, arytenoid adduction, and laryngeal reinnervation. Aside from some select improvements in single outcome parameters, overall, the majority of studies show no difference in improvement of outcomes between techniques.
Conclusions
Four surgical interventions for unilateral vocal fold paralysis are available for treatment of unilateral vocal cord paralysis. Multiple studies show favorable outcomes, but no significant differences between treatment arms based on perceptual, acoustic, quality of life, and laryngoscopic outcomes.
Level of Evidence
NA Laryngoscope, 126:1616–1624, 2016
A 15‐year‐old male with previous open tracheoesophageal fistula (TEF) repair presented with a large, short recurrent TEF. The TEF was denuded with cautery on the tracheal side and the patient was ...intubated with a cuffed endotracheal tube. Suspension microesophagoscopy allowed excellent exposure of the TEF from the esophageal side, which was cauterized. Four sutures were placed endoscopically from the esophageal side, and the TEF remained closed 6 months postoperatively.
Laryngoscope, 134:4114–4117, 2024
Objective
Pediatric esophageal foreign bodies (EFBs) are common and can result in serious complications. Little is known about the influence of socioeconomic status (SES) on EFB ingestion in ...children. The goal was to study SES as a risk factor for dangerous foreign body ingestion and in‐hospital complications in children.
Methods
This was a retrospective cohort study of children presenting to a tertiary care pediatric hospital with an esophageal foreign body from 2010 to 2021. SES was assessed for each patient by linking their postal code to the Ontario Marginalization Index to determine a quintile score across four dimensions of deprivation: residential instability, material deprivation, dependency, and ethnic concentration. Dangerous EFBs were defined as magnets, batteries, sharp objects, or bones. In‐hospital complications included: intensive care unit admission, prolonged length of stay, and postoperative sequelae.
Results
A total of 680 patients were included. Dangerous EFB ingestion was higher for children with increased residential instability (odds ratio OR, 2.1; 95% confidence interval CI, 1.2–3.6) and increased material deprivation (OR, 2.2; CI, 1.9–2.8), which was similarly true for odds of complications. Odds of dangerous EFB ingestion were higher in older children (OR, 1.1; CI, 1.0–1.1) and odds of complications were higher in children with comorbidities (OR, 1.1; CI, 1.0–1.3).
Conclusion
Higher levels of housing instability and material deprivation are associated with dangerous EFB ingestion and complications related to EFB ingestion. These findings emphasize the role that SES plays on child health outcomes and the need for initiatives to mitigate these disparities.
Level of Evidence
3 Laryngoscope, 134:2945–2953, 2024
Pediatric esophageal foreign bodies are common and dangerous. Housing instability and poverty are risk factors for dangerous foreign body ingestion and complications amongst children.
Unilateral vocal fold immobility (VFI) is a known cause of morbidity amongst children following congenital heart surgery. Injection medialization (IM) provides medial distraction and improves glottic ...closure. Limited objective data is available for the effect of IM in young children (<2 years-old) with VFI.
Retrospective case series of infants <2 who underwent IM for VFI after congenital cardiac surgery. Primary outcome was objective reduced risk of aspiration based on Dysphagia and Outcome Severity Scores (DOSS) on Video swallow study (VFSS) performed prior to and within 4 weeks following IM. Secondary analysis included perioperative complications and number of children who were able to avoid NG or G tube placement.
17 children <2 years of age had unilateral VFI after congenital cardiac surgery and underwent IM. The median age at time of initial cardiac surgery was 6 days (IQR 3-7). There was no intraoperative or postoperative stridor or associated complications. All 17 patients had preoperative aspiration noted on VFSS. Average swallowing outcomes on VFSS improved after IM with an increase in DOSS score (preop score 3 (IQR 2-4) to postop score 6.5 (IQR 5-7) P = 0.001). At 2 months following IM, of the patients who had improvement in swallowing function, 50% (n = 6) were able to feed completely orally, 25% (n = 3) were fed orally with an NG wean, and 3 (25%) had a G tube placed.
Initial results suggest that IM is safe and improves early objective swallowing outcomes in children <2 years old with VFI after congenital cardiac surgery.
IV Laryngoscope, 2024.
Introduction
Vocal fold motion impairment (VFMI) is a known consequence after high‐risk cardiac surgery. We implemented a universal laryngeal ultrasound (LUS) screening protocol for VFMI after the ...Norwood and aortic arch surgery. We hypothesized that LUS would accurately identify VFMI and predict postoperative aspiration.
Methods
We implemented a screening algorithm with LUS for patients undergoing high‐risk cardiac surgery at a tertiary care pediatric hospital. Positively screened patients underwent flexible nasolaryngoscopy (FNL). Patients with an abnormal FNL underwent a video‐fluoroscopic swallow study (VFSS). Patient demographics, length of stay, and swallowing outcomes were assessed. Two‐tailed chi square and Wilcoxon rank sum tests were used to assess for differences.
Results
Sixty‐seven patients underwent either Norwood or arch reconstruction over a 16‐month period and underwent universal LUS. The average birth weight was 3.24 kg (SD 0.57). Of the 67 patients, VFMI was identified by LUS and 100% confirmed on FNL in 58.21% (n = 39/67) of patients. Aspiration and penetration on VFSS were higher in the group with VFMI as compared with those without VFMI (53.8% vs. 21.4%, p = 0.008). There was no difference in length of stay between patients who did not have a diagnosis of VFMI and those found to have VFMI (41.0 days vs 45.3 days p = 0.73).
Conclusions
Universal LUS screening for patients following high‐risk cardiac surgery may lead to earlier identification of postoperative VFMI and aspiration. Recognition of VFMI through this universal screening program could lead to earlier interventions and possibly improved swallowing outcomes.
Level of Evidence
3 Laryngoscope, 134:1939–1944, 2024
Universal laryngeal ultrasound screening after high‐risk cardiac surgery including Norwood and aortic arch surgery in infants accurately identifies vocal fold immobility and predicts postoperative aspiration.
IMPORTANCE: Vessel-sealant devices (VSDs) have been popularized for use in thyroid operations; however, the association of their use with postoperative neck hematoma, a rare but potentially fatal ...complication, has not been well studied. OBJECTIVE: To examine the association of VSDs vs conventional hemostasis (CH) in thyroid operations with the development of neck hematoma. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study evaluated 10 903 patients in the Thyroid Procedure–Targeted Database of the National Surgical Quality Improvement Program from January 1, 2016, to December 31, 2017. One-to-one nearest-neighbor propensity score matching was conducted to adjust for differences in baseline covariates, including demographics, comorbidities, indications for thyroid procedure (goiter, Graves disease, malignant and benign thyroid nodule), and several other thyroid-specific characteristics, between the VSD and CH groups. MAIN OUTCOMES AND MEASURES: The primary outcome was postoperative hematoma requiring intervention with open evacuation, return to the operating room, tracheostomy, additional observation, or extended length of stay. Secondary outcomes include recurrent laryngeal nerve injury, operative duration, and hospital length of stay. RESULTS: One-to-one propensity score matching yielded 6522 patients (mean SD age, 52 15 years; 8544 78.4% female) with 3261 in each exposure group such that distribution of observed baseline covariates was not different between groups of the same propensity score. Within the matched cohort, CH was associated with higher odds of neck hematoma compared with VSD (odds ratio, 2.33; 95% CI, 1.55-3.49; P < .001), with 34 (1.0%) hematomas in the VSD group and 78 (2.4%) in the CH group. On the basis of this analysis, the number needed to treat with a VSD to prevent 1 postoperative hematoma was 74. Secondary outcomes included longer length of hospital stay (incidence rate ratio, 1.29; 95% CI, 1.23-1.36; P < .001) in the CH group compared with the VSD group but no difference in the odds of recurrent laryngeal nerve injury (odds ratio, 0.90; 95% CI, 0.73-1.11; P = .32) or operative duration (incidence rate ratio, 0.99; 95% CI, 0.96-1.01; P = .24). CONCLUSIONS AND RELEVANCE: Use of VSDs during thyroid operations was associated with reduced odds of neck hematoma compared with CH techniques without increasing odds of nerve injury. The results suggest that postoperative neck hematoma rates after thyroid surgery may differ based on the hemostasis technique and that these differences should be considered when developing strategies for quality improvement of postoperative outcomes.
Introduction
Flexible nasolaryngoscopy (FNL) is a common, uncomfortable procedure performed to assess the upper airway in infants. Oral sucrose is used during various painful procedures in infants ...but has not been used during FNL. Our objective was to understand the impact of oral sucrose on discomfort in infants undergoing FNL.
Methods
Infants (<12‐months‐old) undergoing FNL in the otolaryngology clinic were randomized to treatment (0.5 mL 24% oral sucrose) or standard management (no sucrose). Sucrose was administered <2 min prior to FNL performed by a single endoscopist. Outcome measures included: EVENDOL pain scale and cry duration and visit duration. Infant discomfort was measured by a second observer who was blinded to treatment group.
Results
Forty‐seven infants were included, 23 were treated with sucrose and 24 with standard management. The median (IQR) age was 3.0 (2–5.7) months. There were no significant differences in age, weight, or sex across groups. The median (IQR) duration of FNL was 35.2 (26.5–58.4) and 36.4 (28.9–51.8) seconds for treatment and standard management groups, respectively. Mean (SD) EVENDOL scores were significantly lower in the sucrose group 4.9 (2.0) than standard group (6.7 2.1) (p = 0.003). Mean cry duration after FNL was significantly shorter in the sucrose group (29.9 20.4 seconds) than the standard group (52.7.0 40.6 seconds) (p = 0.02). Median (IQR) visit duration did not differ across groups (1.1 0.9–1.3 vs. 1.1 0.7–1.4 h p = 0.15).
Conclusion
Oral sucrose given before FNL reduced EVENDOL scores and cry duration after FNL and did not prolong clinic visits in this randomized pilot study.
Level of Evidence
2 Laryngoscope, 134:3826–3831, 2024
Flexible nasolaryngoscopy is a painful procedure performed on infants. Painful procedures are often undertreated in infants due to lack of physician awareness and time constraints and this has long‐term implications on children. Oral sucrose given 2 min before flexible endoscopy successfully treated pain and did not prolong clinic visit duration.
Objective Evaluate implementation of an institutional protocol to reduce the time to removal of esophageal button battery (BB) and increase use of mitigation strategies. Methods We developed a ...protocol for esophageal BB management Zakai's Protocol (ZP). All cases of esophageal BB impaction managed at a tertiary care center before and after implementation from 2011 to 2023 were reviewed. Time to BB removal, adherence to critical steps, and use of mitigation strategies (honey/sucralfate, acetic acid) were evaluated. Results Fifty‐one patients (38 pre‐ZP, 13 post‐ZP) were included. Median age was 2.3 years (IQR 1.3–3.4). After implementation, the time from arrival at the institution to arrival in the operating room (OR) reduced by 4.2 h 4.6 h (IQR 3.9–6.5) to 0.4 h (IQR 0.3–0.6), p < 0.001 and there was improvement in all management steps. The number of referrals direct to otolaryngology increased from 51% to 92%, arrival notification increased from 86% to 100%, avoidance of second x‐ray increased from 63% to 100%, and direct transfer to OR increased from 92% to 100%. Adherence to mitigation strategies such as preoperative administration of honey or sucralfate increased from 0% to 38%, intraoperative use of acetic acid from 3% to 77%, and nasogastric tube insertion from 53% to 92%. Conclusion Implementation of ZP substantially reduced the time to BB removal and the use of mitigation strategies in our tertiary care institution. Additional strategies focused on prevention of BB ingestion, and shortening the transfer time to the tertiary care hospital are required to prevent erosive complications. Level of Evidence Level 3 Case‐series Laryngoscope , 2024
Percutaneous tracheostomy is routinely performed in adult patients but is seldomly used in the pediatric population due to concerns regarding safety and limited available evidence. This study aims to ...consolidate the current literature on percutaneous tracheostomy in the pediatric population.
A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted. MEDLINE, EMBASE, CINAHL, and Web of Science were searched for studies on pediatric percutaneous tracheostomy (age ≤18). The Joanna Briggs Institute and ROBINS-I tools were used for quality appraisal.
Twenty-one articles were included resulting in 143 patients. Patient age ranged from 2 days to 17 years, with the largest subpopulation of patients (n = 57, 40 %) being adolescents (age between 12 and 17 years old). Main indications for percutaneous tracheostomy included prolonged ventilation (n = 6), respiratory insufficiency (n = 5), and upper airway obstruction (n = 5). One-third (n = 47) of percutaneous tracheostomies were completed at the bedside in an intensive care unit. Select studies reported on surgical time and time from intubation to tracheostomy with a mean of 13.8 (SD = 7.8) minutes (n = 27) and 8.9 (SD = 2.8) days (n = 35), respectively. Major postoperative complications included tracheoesophageal fistula (n = 4, 2.8 %) and pneumothorax (n = 3, 2.1 %). There were four conversions to open tracheostomy.
Percutaneous tracheostomy had a similar risk of complications to open surgical tracheostomy in children and adolescents and can be performed at the bedside in a select group of patients if necessary. However, we feel that consideration must be given to the varying anatomical considerations in children and adolescents compared with adults, and therefore suggest that this procedure be reserved for adolescent patients with a thin body habitus and clearly demarcated and palpable anatomical landmarks who require a tracheostomy. When performed, we strongly support using endoscopic guidance and a surgeon who has the ability to convert to an open tracheostomy if required.
•Pediatric percutaneous tracheostomy has a low complication rate and procedure time.•Risk profiles for percutaneous versus open tracheostomy are similar in children.•Percutaneous tracheostomy may be suitable for adolescents with thin body habitus and clearly demarcated anatomical landmarks.•Current data on pediatric percutaneous tracheostomy are heterogeneous and limited.•Future studies should employ more rigorous designs to explore the safety and feasibility of the percutaneous approach in children.
Objective
To review cases of congenital frontonasal dermoids to gain insight into the accuracy of preoperative computed tomography (CT) and magnetic resonance imaging (MRI) in predicting intracranial ...extension.
Methods
This retrospective study included all patients who underwent primary excision of frontonasal dermoids at an academic children's hospital over a 23‐year period. Preoperative presentation, imaging, and operative findings were reviewed. Receiver operating characteristic (ROC) statistics were generated to determine CT and MRI accuracy in detecting intracranial extension.
Results
Search queries yielded 129 patients who underwent surgical removal of frontonasal dermoids over the study period with an average age of presentation of 12 months. Preoperative imaging was performed on 122 patients, with 19 patients receiving both CT and MRI. CT and MRI were concordant in the prediction of intracranial extension in 18 out of 19 patients. Intraoperatively, intracranial extension requiring craniotomy was seen in 11 patients (8.5%). CT was 87.5% sensitive and 97.4% specific for predicting intracranial extension with an ROC of 0.925 (95% CI 0.801, 1), whereas MRI was 60.0% sensitive and 97.8% specific with an ROC of 0.789 (95% CI 0.627, 0.950).
Conclusion
This is the largest case series in the literature describing a single institution's experience with frontonasal dermoids. Intracranial extension is rare and few patients required craniotomy in our series. CT and MRI have comparable accuracy at detecting intracranial extension. Single‐modality imaging is recommended preoperatively in the absence of other clinical indications.
Level of Evidence
4 Laryngoscope, 134:1961–1966, 2024
Frontonasal dermoids are congenital nasal masses that have an association with intracranial extension. Imaging with CT and/or MRI is required for treatment planning. We found no difference between the two imaging modalities in the largest case series published.
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