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To explore patient-reported outcome measures of pediatric paradoxical vocal fold motion through a multi-institutional study of geographically diverse United States medical facilities to assess long-term management and outcomes.Eligible participants8 years of age diagnosed with PVFM over a 10-year period from 7 tertiary pediatric hospitals were invited to complete a survey addressing study objectives.65 participants completed the survey, of whom 80% were female, 75% reported a 3.5 grade point average or better, and 75% identified as competitive athletes or extremely athletic individuals. Participants rated their perceived efficacy of 13 specific treatments. Only five treatments were considered effective by a majority of the participants who tried them. The treatments that participants tried most often were breathing exercises (89.2%), bronchodilator treatments (45%), and allergy medications (35.4%). 78.8% of participants reported receiving more than one treatment and 25% reported receiving a combination of bronchodilators, anticholinergics, and steroids. At the time of PVFM diagnosis, 38% of participants had no idea when their symptoms would completely resolve. 23.3% of participants did not experience symptom resolution until greater than 1 year after diagnosis.Traditional management tools such as breathing exercises and biofeedback treatments may not provide the long-term benefit that providers anticipate. In addition to these commonly used management strategies, highly efficacious techniques such as counseling and lifestyle management should be incorporated into the long-term management of patients whose symptoms are refractory to traditional care.4 Laryngoscope, 2022.

Importance: Vocal fold motion impairment (VFMI) due to neuronal injury is a known complication following thoracic aortic repair that can impair pulmonary toilet function and post-operative recovery. Objective: To demonstrate clinical outcomes of patients undergoing inpatient vocal fold medialization for VFMI after aortic surgery. Design: A 15-year retrospective chart review (2005-2019) of 259 patients with postoperative VFMI after thoracic aortic surgery registry was conducted. Data included demographics, surgery characteristics, laryngology exam, and postoperative clinical outcomes. Medialization procedures consisted of type 1 thyroplasty and injection laryngoplasty. Setting: Tertiary care hospital Participants: Two hundred and fifty-nine patients (median age 61, 71% male) with VFMI post-thoracic aortic repair met inclusion criteria; inpatient vocal fold medialization was performed for 203 (78%) patients. One hundred and twenty-six. (49%) received type 1 thyroplasty and 77 (30%) received injection laryngoplasty procedures at a median 7 days (IQR 5-8 days) from extubation. Main Outcomes: Primary study outcome measurements consisted of median LOS, median ICU LOS, complications intra- and postoperatively, and pulmonary complications (post-medialization bronchoscopies, pneumonia, tracheostomy, etc.). Results: Post-medialization bronchoscopy rates were significantly lower in the medialization (n = 11) versus the non-medialization group (n = 8) (5% vs 14%, P = .02) and significantly higher in the injection laryngoplasty group (n = 77) versus thyroplasty group (n = 126) (10% vs 2%, P = .02). Further analysis revealed no significant difference in overall LOS and pulmonary complications between the techniques. Conclusion: Inpatient thyroplasty and injection laryngoplasty are both effective vocal fold medialization techniques after extent I and II aortic repair. Thyroplasty may have a small pulmonary toilet advantage, as measured by need for post-medialization bronchoscopy, compared to injection laryngoplasty.

Objectives: To evaluate videofluoroscopic swallow study (VFSS) findings in infants with dysphagia and without prior diagnoses, and to characterize the outcomes and any diagnoses that follow. Methods: A chart review of all pediatric patients who received a VFSS at a tertiary children’s hospital from November 2008 to March 2017 was performed. Results: There were 106 infants (57 males and 49 females) with 108 VFSS. VFSS was normal in 18 (16.98%) infants. Regarding airway protection, 50 (47.17%) infants had laryngeal penetration, and 8 (7.55%) had tracheal aspiration; 3 (2.83%, 37.5% of all aspirators) exhibited silent aspiration. Of the 75 infants with minimum 2-year follow-up, 35 (46.67%) had no sequelae of disease and received no diagnoses. The most common diagnoses and pathologic sequelae were gastroesophageal reflux (n = 18, 24.00%), asthma (n = 8, 10.67%), laryngomalacia (n = 6, 8.00%), and tracheomalacia (n = 4, 5.33%), all consistent with United States pediatric data on prevalence. All infants (n = 51) with follow-up for dysphagia had resolution of symptoms within 9 months from VFSS order date. Conclusions: Otherwise healthy infants may show signs of dysphagia and not develop later illness. Parents can thus be counseled on the implications of dysphagia in a previously healthy infant. Our findings provide comparative statistics for future research in pediatric dysphagia.

Objectives: Implanted vagal nerve stimulators (VNS) are an accepted therapy for refractory seizures. However, VNS have been shown to affect vocal fold function, leading to voice complaints of hoarseness. We present a case of intermittent VNS-related vocal fold paralysis leading to dysphonia and dysphagia with aspiration in a pediatric patient. Methods: This is a case report of a patient at a tertiary hospital evaluated in pediatric swallow and voice clinics. Patient and mother gave verbal consent to be included in this case report. Results: Indirect laryngeal stroboscopy was performed demonstrating full vocal fold mobility with VNS off and left vocal fold paralysis in lateral position and glottic gap with VNS on. Voice measures were performed demonstrating decreased phonation time, lower pitch, and decreased intensity of voice with VNS on. Flexible endoscopic evaluation of swallowing demonstrated deep penetration alone with VNS off and deep penetration with concern for aspiration with VNS on. Conclusions: While the majority of cases of vocal fold movement impairment associated with VNS have been noted to have a medialized vocal fold with VNS activation, we describe a case of intermittent vocal fold lateralization associated with VNS activation with resultant voice changes and aspiration.

Objectives: Cerebral palsy (CP) in infants can affect global motor function and lead to swallowing difficulties. This study aims to characterize oral and pharyngeal swallowing dynamics in infancy of patients later diagnosed with CP and to determine if swallow study performance in early infancy is associated with later CP severity and characteristics. Methods: This is a retrospective chart review of infants who underwent videofluoroscopic swallow studies (VFSS) between 6/2008 and 10/2018 at a tertiary children’s hospital, and were later diagnosed with CP. Demographic data, CP characteristics and metrics, and VFSS findings were collected and analyzed. Results: There were 66 patients included in this study. The average age at the time of VFSS was 4 months (range: 0.3-12 months), 42% of patients were female, and 50% of patients were born premature. In our sample, 86% of patients presented with oral dysphagia, and 76% with pharyngeal dysphagia. Laryngeal penetration in isolation was seen in 39% of patients, and tracheal aspiration was seen in 38% of patients. Of these tracheal aspiration events, 64% were silent. At the time of VFSS, 58% of patients had a nasogastric tube, 12% had a gastrostomy tube, and 3% had a prior hospitalization for pneumonia. Rates of penetration and aspiration in early infancy did not consistently correlate with prematurity, type of CP (spastic, non-spastic, or mixed), degree of paralysis (quadriplegic, hemiplegic, or diplegic), or severity of Gross Motor Function Classification System (GMFCS) score. Conclusion: While there was not a consistent correlation of swallowing dynamics in infancy with later gross motor categorizations of CP, the results of this retrospective review highlight the essential role of early clinical and videofluoroscopic swallowing evaluations to identify oral and pharyngeal swallowing dysfunction in this patient population.

To determine how often children with airway injury at the time of tracheostomy develop airway stenosis.A 7-year retrospective review of a prospectively maintained database of pediatric patients who underwent endotracheal intubation followed by tracheostomy with concurrent and follow-up direct laryngoscopy.Tertiary care hospital.Outcomes included glottic or subglottic injury and progression to stenosis. Univariate and multivariate analyses were performed via SPSS.Of the 222 patients (median age at surgery, 0.6 years; 54% male) who met study criteria, 46% had airway injury at the time of tracheostomy. Patients with congenital cardiovascular disease had 2.33-times increased risk of developing airway injury (Intubated patients with evidence of glottic or subglottic injury at the time of tracheotomy are more likely to develop airway stenosis than those without. Congenital heart disease was associated with twice the risk of developing airway injury, while progression to stenosis was associated with younger age, prematurity, and/or comorbid diagnoses.

OBJECTIVES/HYPOTHESIS: Vocal fold movement impairment (VFMI) in infants and children is most commonly evaluated by flexible nasolaryngoscopy (FNL). FNL in this population can be challenging due to movement, floppy supraglottic structures, or secretions. Laryngeal ultrasound (LUS) may be an alternative, less invasive means of evaluating VFMI that also decreases aerosolization during the COVID-19 pandemic. The primary objective was to examine LUS interpretation proficiency for VFMI via an educational module. A secondary outcome was to determine whether quantitative measurements increase interpretation accuracy. STUDY DESIGN: Prospective cohort trial. METHODS: Medical students, residents, fellows, faculty, and staff were recruited to complete the module, composed of a 13-minute teaching video followed by 20 cases. Participants determined both qualitatively (subjective assessment) and then quantitatively (through protractor measurements of the vocal fold to arytenoid angle) whether there was normal versus impaired vocal fold mobility. RESULTS: Thirty participants completed the LUS training module, and about one-third were otolaryngology residents. On average, each participant correctly identified 18 cases. The mean rank percent correct for quantitative measurements was significantly higher than that of qualitative interpretations (P < .0001). Measurements significantly caused participants to change their answer correctly compared to incorrectly (P < .0001). As the module progressed, there was no significant trend of more correct interpretations (P = .30). The sensitivity was higher for quantitative interpretations (89.0% vs. 87.3%) but specificity remained unchanged (92.6%). CONCLUSION: Quantitative measurements may increase LUS interpretation accuracy. There was not a specific number of cases interpreted to achieve learning proficiency. LUS is an easily learned method to evaluate for VFMI across all training levels. LEVEL OF EVIDENCE: 3 (local cohort study nonrandomized) Laryngoscope, 2021.

This paper will examine recent advances in the assessment and management of pediatric unilateral vocal fold motion impairment (VFMI). Unilateral VFMI can have a considerable impact on pediatric voice, swallowing, and pulmonary hygiene. In addition, postoperative VFMI in children undergoing congenital cardiac procedures is associated with longer lengths of stay. Laryngeal ultrasound (LUS) is an adjunctive tool that can be used to assess vocal fold mobility in patients who cannot tolerate traditional flexible nasolaryngoscopy (FNL) or for those in whom FNL is non-diagnostic. Laryngeal electromyography (LEMG) can help differentiate neuronal causes of vocal fold paralysis from mechanical cricoarytenoid joint fixation. Recent data suggests that preoperative LEMG may be used to predict voice outcomes after non-selective laryngeal reinnervation (NSLR). NSLR is a promising treatment modality for permanent vocal fold medialization in children. An emphasis on early diagnostic and prognostic techniques, such as the use of LUS and LEMG, can inform decision-making in unilateral VFMI treatment. NSLR is emerging as the preferred treatment modality for pediatric unilateral VFMI due to neuronal injury.

Objectives: To examine whether social determinants of health (SDH) factors are associated with time to diagnosis, treatment selection, and time to recurrent surgical intervention in idiopathic subglottic stenosis (iSGS) patients. Methods: Adult patients with diagnosed iSGS were recruited prospectively (2015-2017) via clinical providers as part of the North American Airway Collaborative (NoAAC) and via an online iSGS support community on Facebook. Patient-specific SDH factors included highest educational attainment (self-reported), median household income (matched from home zip code via U.S. Census data), and number of close friends (self-reported) as a measure of social support. Main outcomes of interest were time to disease diagnosis (years from symptom onset), treatment selection (endoscopic dilation [ED] vs cricotracheal resection [CTR] vs endoscopic resection with adjuvant medical therapy [ERMT]), and time to recurrent surgical intervention (number of days from initial surgical procedure) as a surrogate for disease recurrence. Results: The total 810 participants were 98.5% female, 97.2% Caucasian, and had a median age of 50 years (IQR, 43-58). The cohort had a median household income of $62 307 (IQR, $50 345-$79 773), a median of 7 close friends (IQR, 4-10), and 64.7% of patients completed college or graduate school. Education, income, and number of friends were not associated with time to diagnosis via multivariable linear regression modeling. Univariable multinominal logistic regression demonstrated an association between education and income for selecting ED versus ERMT, but no associations were noted for CTR. No associations were noted for time to recurrent surgical procedure via Kaplan Meier modeling and Cox proportional hazards regression. Conclusions: Patient education, income, and social support were not associated with time to diagnosis or time to disease recurrence. This suggests additional patient, procedure, or disease-specific factors contribute to the observed variations in iSGS surgical outcomes.

Unilateral vocal fold movement impairment (VFMI) in the pediatric population presents unique challenges. Thoughtful and innovative methods of diagnosis, prognostication, and intervention have recently influenced the management of VFMI in children. This article presents updates on the natural history of pediatric VFMI, use of laryngeal ultrasound (LUS) and laryngeal electromyography (LEMG) as diagnostic tools, and optimal management strategies for pediatric unilateral VFMI. Long-term follow-up studies for pediatric patients diagnosed with VFMI described a substantial number of children that have recovery of VFMI well after 12 months, contradicting the conventional teaching that recovery after 1 year is unlikely. LUS performs well compared to the gold standard flexible nasolaryngoscopy (FNL) in identifying VFMI with significantly less physiologic impact. LEMG can be used to assist in determining etiology of VFMI and may play a role in predicting recovery and outcomes of interventions. Recent data has demonstrated that reinnervation is highly effective in managing dysphonia and aspiration in children with VFMI. Children diagnosed with VFMI should be followed at regularly scheduled intervals until resolution of their VFMI. LUS is an alternate tool that should be considered in medically fragile children susceptible to alterations in physiologic parameters. LEMG is a useful adjunct for elucidating neuronal versus mechanical VFMI. Recent data suggests that reinnervation should be considered as a primary surgical intervention for neuronal unilateral VFMI.

To explore biomarkers that are candidates for understanding potential degeneration to malignancy of vocal fold leukoplakia (VFL), with the goal of guiding future diagnostic and treatment recommendations.PubMed and Medline search engines.A systematic review was conducted by searching the following key words:Prognostic biomarkers in the 16 studies are generally divided into 3 categories according to their biological roles: proliferation (Ki-67, CK-1 RS14024 SNP), cell cycle control (P53, p16, cyclin D1, p57kip2, interleukin-10 [IL-10], miR-10a, and miR-34c), cell adhesion, and invasion (neutrophil-to-lymphocyte ratio, OPN/CD44v6 axis, MMP-1, vascular endothelial growth factor A, MMP-9, serpin peptidase inhibitor 1, plasminogen activator, CTNN/B1, β-catenin, NANOG, HERG1). The prognostic use of these biomarkers is limited due to the variable methodologies, study design, assay methods, and statistical analysis performed.Prognostic factors in vocal fold leukoplakia have important clinical implications regarding the potential for malignant degeneration. Although further study is needed, the currently available evidence suggests that p53, p16, cyclin D1, IL-10, NLR, OPN and CD44v6, CTNNB1, and CTTN and FAK might be of particular interest in determining prognosis of VFL as related to malignancy. Future, large, well-designed, prospective studies are expected to determine the prognostic power of these biomarkers before their implementation in routine clinical practice.

To compare measurements of the pediatric subglottis obtained by surgeon-performed ultrasound and endoscopy.Prospective observational comparison-of-methods study.Tertiary care pediatric hospital.Thirty-one patients who underwent direct laryngoscopy from May 2017 to July 2018 were recruited. Transcervical ultrasound was used to visualize the vocal folds, subglottis, and cervical trachea. The anterior-posterior (AP) and transverse (TV) diameter of the subglottic space were measured endoscopically and via ultrasound by 2 independent evaluators. Measurements were compared for correlation, bias, and agreement. A clinically acceptable bias for subglottic diameter was assumed to be 0.5 mm or less.The median age of enrolled patients was 2.6 years (range, 4 months-13.3 years). Endoscopic subglottic AP and TV measurements ranged from 3.33 mm to 14.81 mm and from 4.44 mm to 11.65 mm, respectively, while ultrasonographic AP and TV measurements ranged from 4.57 mm to 9.85 mm and from 3.77 mm to 8.96 mm. Pearson coefficient showed strong a correlation for both endoscopic and ultrasound AP (Endoscopic and ultrasonography measurements of the pediatric subglottic airway were strongly correlated. The discrepancy between AP and TV measurements was less than 0.5 mm. Ultrasound of the subglottis may be an alternative to endoscopic assessment of the airway for measurement of the subglottic airway in children in select cases.

The purpose of this study is to evaluate the association between type-1 laryngeal clefts and pathogenic bacterial growth in the lower airway in children.Retrospective chart review.A retrospective chart review was conducted for all children who underwent direct laryngoscopy, flexible bronchoscopy with bronchoalveolar lavage (BAL), and esophagogastroduodenoscopy, under a single anesthetic event from 2015 until 2018 at an academic tertiary referral center. Type-1 laryngeal clefts were diagnosed as an interarytenoid depth at or below the level of the vocal folds, on direct laryngoscopy, via palpation by a fellowship-trained pediatric otolaryngologist. Pathogenic bacterial growth in the lower airway was defined as presence of BAL culture growth of nonrespiratory flora.A total of 217 patients were identified. Type-1 laryngeal cleft was significantly associated with chronic cough (P = .0016) and cough with feeds (P .0001). However, an abnormal video fluoroscopic swallow study was not found to be significantly associated with type-1 laryngeal cleft (P = .92) or pathogenic bacterial growth in the lower airway (P = 0.19). Overall, 122 (56%) patients were diagnosed with type-1 laryngeal cleft, 75 (35%) had pathogenic bacterial growth in the lower airway and 50 (23%) had both type-1 laryngeal cleft and pathogenic bacterial growth in the lower airway. Type-1 laryngeal cleft was significantly associated with pathogenic bacterial growth in the lower airway on both univariate analysis (P = .0307) and multivariate analysis (P = .0298, odds ratio 1.922, 95% confidence interval 1.066-3.467).Children with type-1 laryngeal clefts are at higher risk of having pathogenic bacterial growth in the lower airway.4 Laryngoscope, 132:1825-1828, 2022.

Extrarenal malignant rhabdoid tumors (MRT) are highly aggressive tumors of childhood with a poor overall prognosis. While most commonly found within the kidney and central nervous system, MRT can also occur in other locations and present highly specific challenges for pediatric surgical providers in an effort to achieve a meaningful resection. Cervical rhabdoid tumors are extremely rare. We report the multidisciplinary management of a patient with a complex cervicothoracic malignant rhabdoid tumor who underwent successful surgical resection with a greater than one year survival.

OBJECTIVES/HYPOTHESIS Infants who undergo congenital heart surgery are at risk of developing vocal fold motion impairment (VFMI) and swallowing difficulties. This study aims to describe the dysphagia in this population and explore the associations between surgical complexity and vocal fold mobility with dysphagia and airway protection. STUDY DESIGN Retrospective chart review. METHODS This is a retrospective chart review of infants (age

OBJECTIVES/HYPOTHESISAL To analyze tracheostomy-related complications in pediatric patients with scoliosis. STUDY DESIGN Retrospective chart review. METHODS A retrospective chart review of all patients with tracheostomy and scoliosis was performed at a single institution. The charts were reviewed for variables including difficulties with tracheostomy tube changes, poor positioning of tube, abnormal appearance of trachea, and emergency room visits and admissions for complications. Decannulation rates were also identified. RESULTS About 102 patients met inclusion criteria, 96 (94.1%) had scoliosis involving the thoracic spine, and 4 had scoliosis involving the cervical spine; 13 (12.8%) patients had documented poor positioning on tracheoscopy; 31 patients (30.3%) had at least one emergency room visit or admission for complications, such as accidental decannulation or bleeding from the tracheostomy; 19 (18.6%) patients required at least one tube change due to poor positioning, with 7 (6.9%) requiring multiple changes; 18 (17.7%) had reported difficulties with home tube changes. Custom length tubes were required in 9 patients (8.8%). The level of scoliosis was not associated with any of these complications. Abnormalities of the trachea, such as tortuosity, obstructive granulomas, or tracheomalacia, were seen in 35 patients (34.3%) on bronchoscopy. Scoliosis repair was performed in 18 patients (17.65%), of which two achieved decannulation. Ten patients (9.8%) overall were decannulated. CONCLUSION A portion of patients with scoliosis who are tracheostomy-dependent have anatomical abnormalities of the trachea and poor positioning of the tracheostomy tube. Decannulation rates are also lower in this population compared to the literature. Further work is required to elucidate if scoliosis predisposes patients toward tracheostomy-related complications. LEVEL OF EVIDENCE 4 Laryngoscope, 2021.

OBJECTIVES/HYPOTHESIS To identify the most influential publications in laryngology since 2000. STUDY DESIGN Modified Delphi process. METHODS Samples of laryngologists drawn from editors of leading journals, organization officers, and thought leaders were invited to participate in a modified Delphi identification of influential laryngology papers. Influential was defined as follows: yielding meaningful practice changes, catalyzing further work as a foundation for an important topic, altering traditional views, or demonstrating durability over time. Quality and validity were not among the selection criteria. Each participant nominated 5 to 10 papers in Round 1. These nominations, augmented with papers from bibliometric analysis, were narrowed further in Round 2 as participants identified their top 20. The 40 papers with the most Round 2 votes were discussed by video conference and then subjected to Round 3 voting, with each participant again selecting their top 20 most influential papers. Final results were collated by the number of Round 3 votes. RESULTS Sixteen of 18 invited laryngologists participated overall (all 16 in Rounds 1 and 3; 14 in Round 2). Twenty-one papers were identified as most influential. One paper appeared on all 16 Round 3 lists; three papers with eight (50%) votes each were lasted to make the list. Eleven of these 21 focused on voice; three each related to cancer, airway, and swallowing; and one encompassed all of these clinical areas. CONCLUSIONS This list of 21 influential laryngology papers serves to focus further research, provides perspective on recent advances within the field, and is an educational resource for trainees and practicing physicians. LEVEL OF EVIDENCE N/A Laryngoscope, 2021.

Objective 22q11.2-deletion syndrome is a genetic condition that affects 1:3000 births. In addition to cardiac anomalies and immunosuppression, individuals with 22q11.2-deletion syndrome can have feeding difficulties from birth resulting in failure to thrive and infections. This study aims to characterize the dysphagia seen in infants with 22q11.2-deletion syndrome. Methods This is a retrospective chart review of infants with 22q11.2-deletion syndrome who underwent videofluoroscopic swallow studies (VFSS) from June 1, 2008 to January 1, 2018 at a tertiary children's hospital. Demographic data and VFSS findings were collected. Results Forty-four patients were identified, 52% were females, and mean age at VFSS was 71 days. In their lifetime, 30% of the patients had at least 1 episode of pneumonia, 66% had NG-tube placement and 41% required G-tube placement. 93% had oral-phase dysphagia, and 89% had pharyngeal-phase dysphagia. Twenty-two patients (50%) demonstrated evidence of penetration. Eighteen patients (41%) showed tracheal aspiration. Of the patients that showed tracheal aspiration, 83% of them aspirated "silently." Three patients (7%) had upper esophageal sphincter (UES) opening dysfunction. Conclusion Vast majority of the infants with 22q11.2-deletion syndrome referred for swallow studies demonstrated evidence of dysphagia in both oral and pharyngeal phases with deficits in swallow physiology not yet documented in other studies. Importantly, more than 80% of these infants showed evidence of "silent" tracheal aspiration, which can lead to recurrent pneumonia and significant morbidity if overlooked. Prompt recognition is paramount in these infants to intervene early and reduce long-term complications and also develop targeted interventions. Level of evidence 4 Laryngoscope, 130:2532-2536, 2020.

Pediatric dysphonia is common; however, not all vocal fold pathology in children is due to nodules. Laryngeal stroboscopy (transoral or transnasal) often is essential for the diagnosis of other not-nodule lesions. As in adults, multidisciplinary care with a speech language pathologist helps with patient buy-in for therapy. Breathy dysphonia due to glottic incompetence may be related to vocal fold movement impairment (VFMI) or posterior glottic insufficiency. There are several medialization procedures available for children with VFMI due to recurrent laryngeal nerve injury.

To determine adverse events after endoscopic flexible vs endoscopic rigid cricopharyngeal myotomy for treatment of Zenker's diverticulum (ZD).Systematic review of MEDLINE, Web of Science, CINAHL, Clinicaltrials.gov, and Cochrane Central Register of Controlled Trials for all years according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Additional studies were identified from review citations and a by hand search of manuscripts referencing ZD.A structured literature search was conducted to identify studies for this systematic review. Methodological Index for Non-randomized Studies (MINORS) criteria were applied to assess study quality. For inclusion, each study had to provide data for at least 10 adult patients who had undergone endoscopic ZD repair reporting clear association with the postprocedure course in each case. Data extracted included all reported adverse events, recurrences, follow-up, and operative times.In total, 115 studies were included. All but 8 were retrospective case series. Sixty-one reported series of patients after rigid endoscopic stapler repair, 31 after rigid laser repair, and 13 with other rigid endoscopic instruments. Twenty-nine flexible endoscopic studies were included. Mortality, infection, and perforation were not significantly more likely in either the rigid or the flexible group, but bleeding and recurrence were more likely after flexible endoscopic techniques (20% vs10% and 4% vs 0%, respectively). Dental injury and vocal fold palsy were reported rarely in the rigid endoscopic groups.Adverse events are rare after endoscopic Zenker's repair. The flexible approach minimizes exposure limitations and can be completed in some patients without general anesthesia. Transoral rigid approaches result in fewer revision surgeries compared with flexible diverticulotomy.

Objective Health care disparities are noted between different socioeconomic groups; it is crucial to recognize and correct disparities, if present, that extend to children with hearing loss. The objective of the study is to evaluate the effect of socioeconomic status (SES) on access to hearing rehabilitation and speech and language therapy and outcomes in children with hearing loss. Methods Retrospective Chart Review of children diagnosed with hearing loss at 3 tertiary care academic centers from 2010 to 2012. Two hundred patients were then randomly selected from each institution for analysis. International and self-pay patients were excluded. They were separated into two groups based on SES using insurance coverage as proxy for financial status (private insurance versus Medicaid). Main outcome measures included number of hearing aid evaluations recommended andcompleted, compliance with hearing aids use, diagnosis on speech therapy evaluations, participation in speech therapy, and outcomes noted on the last speech therapy session in patients’ medical record at time of study completion. Results 600 patients were identified by random selection out of total of 3679 patients. 18 were excluded because they were international pay or self-pay. Of 582 patients, 299 (51.4%) had private insurance and 283 (48.6%) had Medicaid. The pure tone average (PTA) at initial diagnosis did not differ between the two populations (left ear p = 0.74, right ear p = 0.68). There was no significant difference in the number of hearing aid evaluations recommended (p = 0.49), hearing aid evaluation completed (p = 0.68), or documented hearing aid compliance (p = 0.68) between the two populations. Similarly, there was no significant difference in the presence of speech delay (p = 0.62), the receipt of speech therapy (p = 0.49), or speech language outcomes between the two groups (p = 0.45). Conclusions This study suggests that despite lower socioeconomic status, in children with hearing loss, Medicaid allows equivalent access to hearing rehabilitation and speech therapy as their privately insured counterparts and children achieve similar speech and language outcomes.

Purpose of review Ansa to recurrent laryngeal nerve reinnervation, otherwise known as a nonselective laryngeal reinnervation (NSLR), is growing in popularity for the management of pediatric unilateral neuronal vocal fold movement impairment (VFMI). In this chapter, we will review the current treatment options for neuronal VFMI and role that NSLR plays in the treatment algorithm. Recent findings In 2018, Bouhabel and Hartnick published a survey of fellowship trained pediatric otolaryngologists and found an increasing comfort level with NSLR. Respondents felt that NSLR resulted in favorable subjective and objective postsurgical voice outcomes. Furthermore, NSLR may decrease the risk of aspiration in children with neuronal VFMI. Although NSLR appears to work, the voice results are not perfect for all children. Further work is being done to understand which preoperative variables, such as age, time from injury, and preop laryngeal electromyography, may predict a better voice outcome. Summary A variety of treatment options exist for unilateral neuronal VFMI. Recent data and developments demonstrate the effectiveness of reinnervation as a potential first-line surgical intervention in children with unilateral neuronal VFMI.

Introduction Options for imaging for evaluation of pediatric patients with unilateral sensorineural hearing loss (USNHL) include computed tomography (CT) and magnetic resonance imaging (MRI). Although both CT and MR imaging provide valuable information in the evaluation of pediatric patients with USNHL, debate remains regarding which imaging modality is most ideal and should be the preferred study for these children. The objective of this study is to evaluate and compare the diagnostic yield of CT versus MRI in children with USNHL. Methods A multi-institutional retrospective chart review was conducted. Pediatric patients with hearing loss (diagnosis codes 389.00–389.22) seen between 2010 and 2012 at three tertiary care centers were identified. Only patients with USNHL and imaging studies were reviewed and results of CT and MRI for each patient were examined and compared. Cochleovestibular or central nervous system findings known to directly correlate to SNHL were noted as positive findings on imaging. McNemar's test was used to compare patients with positive CT and MRI results. Results A total of 219 patients between the ages of 0–18 years with USNHL who underwent CT and/or MRI were identified. Imaging abnormalities were found in 41/96 patients who underwent MRI with overall diagnostic yield of 42.7% and 69 of 188 patients who underwent CT with overall diagnostic yield of 36.7%. For patients who underwent both imaging modalities (n = 65), there was no statistically significant difference in positive findings detected by CT vs MRI (p > 0.05). Conclusions Both CT and MR imaging have similar overall diagnostic yield when used to evaluate children with USNHL. Parents and patients should be counseled regarding cost, test duration, radiation exposure, need for sedation, and diagnostic accuracy associated with each imaging modality and these factors should be considered to select the appropriate diagnostic study.

Recurrent respiratory papillomatosis (RRP) is a benign tumor of the respiratory tract associated with human papillomavirus 6 and 11. Patients undergo multiple surgical debridements for management of growing papilloma. Adjuvant treatment options for RRP in children are often ineffective and do not decrease the need for repeated surgical debridement. We report on three patients with severe disease refractory to surgery who were treated with 10 mg/kg systemic bevacizumab every 4 weeks. All patients had improvement in voice and reduced need for surgical debridement. Interval between bevacizumab doses was gradually increased to every 8-12 weeks. Adverse events included mild proteinuria and self-resolving epistaxis.

Acute macroglossia and laryngeal edema are rare adverse side effects that can cause life-threatening airway obstruction. We report a case of acute macroglossia that began after initiation of ethosuximide in a 15-year-old female with severe medically refractory epilepsy. Macroglossia worsened over the next two weeks of ethosuximide administration, preventing extubation. Macroglossia and laryngeal edema improved upon ethosuximide wean, and completely resolved after discontinuation. The patient was extubated successfully, with precautionary nasal trumpet placement and dexamethasone administration prior to extubation. In medically complex patients on multiple pharmacologic agents, anti-epileptic drugs should be suspected as a possible cause of acute macroglossia.

OBJECTIVE The goal of this study was to use computed tomography (CT) volumetric analysis to assess the effect of age, gender, height, body mass index (BMI), and ethnicity on vocal fold volume in patients with normal larynges. STUDY DESIGN Retrospective cross-sectional study. METHODS Vocal fold length, width, and height were measured in a total of 105 patients without a history of laryngeal or thyroid pathology on thin-section soft-tissue neck CTs. The product of the three dimensions was used to calculate vocal fold volume. Simple and multiple linear regression analyses were used to assess for an association between vocal fold volume and age, gender, height, BMI, and ethnicity. Intraclass correlation coefficients (ICCs) were estimated to evaluate the degree interobserver and intraobserver agreement. RESULTS Vocal fold volume was not associated with age, BMI, or ethnicity. Gender-adjusted height (P = .002) and height-adjusted gender (P = .016) were significantly associated with volume. Height remained significantly associated with volume after stratifying by gender (P

Background Vocal fold movement impairment (VFMI) secondary to neuronal injury is a known risk after aortic surgery. Total arch replacement is technically challenging, and the incidence of vocal fold movement impairment secondary to neuronal injury after this surgery is unknown. This study examined the incidence of VFMI after total arch replacement and medialization treatment outcomes. Study design Retrospective cohort study. Methods All patients who underwent total arch replacement at a tertiary care center over 11 years (2006-2017) were identified through an institutional database. End points included evidence of VFMI on flexible laryngoscopy, time to diagnosis, time to treatment, need for reintubation, and intensive care unit (ICU) and hospital length of stay. Results Of the 358 patients who underwent total arch replacement, 63 (20%) were diagnosed with VFMI during their initial inpatient stay. Fifty patients (79%) VFMIs were left-sided, nine (14%) were right-sided, and four (6%) were bilateral. Thirty-nine patients (62%) underwent inpatient vocal fold medialization: 28 (72%) by injection laryngoplasty and 11 (28%) by type 1 thyroplasty. Those with unilateral VFMI had longer ICU (8.9 days) and hospital (19.4 days) than those with no VFMI (5.7 and 16.1 days). Among patients with unilateral VFMI, those who underwent inpatient vocal fold medialization trended toward shorter ICU (6.2 vs. 14.4 days, P = .03) and hospital stays (20.1 vs. 23.3 days, P = .4) than patients who did not have a medialization procedure. Conclusion The overall incidence of VFMI after total arch replacement in our series was 20%. Both the right and left vocal folds are potentially at risk from a total arch replacement; consequently, the distribution of injury in our cohort was more heterogeneous than in other series. Level of evidence 3 Laryngoscope, 129:699-703, 2019.

Acute croup is a common admitting diagnosis for pediatric patients. If a patient is not responding to medical management for presumed croup, the otolaryngology team is occasionally consulted for direct laryngoscopy and bronchoscopy (DLB) to rule out tracheitis or another airway pathology. We conducted a study to determine if inpatient DLB in acute croup is safe and efficacious and to correlate preoperative vital signs with intraoperative findings. We reviewed the charts of 521 patients with an admitting diagnosis of acute tracheitis, acute laryngotracheitis, or croup. Of this group, 18 patients—11 boys and 7 girls, aged 1 month to 3.3 years (mean: 1.3 yr)—had undergone inpatient DLB. Comorbidities, complications, and level of care were also analyzed. Five patients (28%) had gastrointestinal reflux disease (GERD), and 4 had previously undergone intubation (22%). Eleven patients (61%) had concurrent airway pathology, 7 of whom (39%) required operative intervention. Preoperative mean body temperature and the increase in mean temperature were significantly higher in tracheitis patients than in the non-tracheitis patients. Preoperative change in respiratory rate was elevated when another airway pathology was present (p = 0.047). Only patients who were in the intensive care unit (ICU) preoperatively were intubated in the operating room, and only 1 patient required a postoperative escalation in the level of care. Our study found that performing inpatient DLB in patients hospitalized with croup is reasonably safe and provides a sufficient yield for identifying tracheitis or other airway pathology in selected populations. Preoperative vital signs can be suggestive of tracheitis or additional unexpected airway pathology. Recurrent croup, a history of GERD or previous intubation, and preoperative admission to the ICU increase the yield of DLB.

Posterior glottic insufficiency (PGI) is a triangular or keyhole aperture between the vocal processes and the posterior laryngeal wall. It is the result of inadequate arytenoid closure and apposition, often a complication of long-term indwelling endotracheal tubes. Although many factors affect the likelihood of intubation-related chronic laryngeal injuries, such as PGI, the duration of intubation and the physical characteristics of the endotracheal tube are the most impactful. The endotracheal tube’s presence causes sustained pressure on the larynx, thereby inducing ischemia and infarction of the mucosal and mucoperichondrial capillaries. The resultant pathology is broken into a sequence of fundamental lesions: edema, ulceration, granulation tissue, ulcerated troughs, and chronic healed furrows. From these pressure-induced lesions, chronic laryngeal injuries (not limited to PGI) may develop. Treatment options for PGI include endoscopic posterior cricoid reduction laryngoplasty (EPCRL), aryepiglottic fold grafts, and grafting of the buccal mucosa into the damaged interarytenoid space. Pathogenesis and injuries may be assessed with rigid telescope and the patient under general anesthesia, and tube removal and potentially tracheotomy can be considered upon discovery of deep ulceration.

Paradoxical vocal fold motion (PVFM) is a laryngeal disorder where episodic, inappropriate adduction of the true vocal cords during inspiration causes sudden respiratory difficulty or distress. This chapter discusses approaches to diagnosis, assessment, and management of the disorder in a pediatric population from both speech-language pathologist and otolaryngologist perspectives.

Summary Background Laryngeal chondrosarcoma (LCS) is an exceedingly rare malignancy and least frequently reported in the epiglottis. Methods and Results We report a case of a 71-year-old male smoker who presented with sore throat, dysphagia, and odynophagia for 3 months. Computed tomography scan revealed an inhomogeneously enhancing necrotic mass emanating from the right epiglottis and traveling along the aryepiglottic fold. The mass was removed via endoscopic en bloc laser resection. Histopathological examination of the biopsied specimen confirmed low-grade LCS of the epiglottis. Conclusion Differentiating low-grade LCS from laryngeal chondroma is a challenging task with an increased risk of potential misdiagnosis. This case study reinforces the need for a histopathological examination in forming the basis for ongoing management and follow-up observations. Timely surgery remains the optimal, primary means of treatment notwithstanding the rarity of LCS.

Objectives To evaluate the findings and compare the diagnostic yield of computed tomography (CT) versus magnetic resonance imaging (MRI) in children with bilateral sensorineural hearing loss (BSNHL). Study design Multi-institutional retrospective review. Setting Three tertiary referral centers. Methods A multi-institutional retrospective chart review was performed in patients under the age of 18 years with BSNHL (diagnosis codes 389.00–389.22) who underwent both CT and MRI from 2010 to 2012. An abnormal imaging finding was defined as an abnormality of the cochleovestibular or central nervous system known to directly correlate with sensorineural hearing loss. Diagnostic yield of CT versus MRI was compared by McNemar's test. Results Of 2081 charts reviewed, 313 patients met inclusion criteria. The diagnostic yield of CT and MRI were 25% and 18%, respectively. Approximately one-quarter of patients had an abnormal finding on CT or MRI. The concordance rate was 92%. CT was more likely to yield an abnormal finding versus MRI (p-value = 0.0001). The most common findings on CT were cochlear and semicircular canal abnormalities. On MRI, the most common findings were cochlear nerve aplasia/hypoplasia and semicircular canal abnormalities. Conclusions This study evaluates and directly compares the diagnostic yield of CT versus MRI for pediatric BSNHL. While both modalities have important and often complementary diagnostic utility, CT had superior diagnostic yield in identifying abnormalities associated with BSNHL.

Objective To determine whether the risk of developing a tracheocutaneous fistula (TCF) increases with longer tracheostomy dependence times in children. Study Design Retrospective review of medical records. Method A retrospective chart review was conducted for all children who both underwent tracheotomy and were decannulated between 2002 and 2011 at a tertiary children's hospital. Charts were analyzed for duration of tracheostomy and evidence of TCF up to 12 months. Data for these criteria was available on 164 out of 182 patients. Results A significant difference in the duration of tracheostomy dependence between children with and without resultant TCF was determined by the Wilcoxon signed rank test (P = 0.0003). The relative risk (RR) of a persistent TCF was significantly increased when the duration of tracheostomy dependence was greater than 24 months (RR = 2.5217, P < 0.005) when compared to those decannulated before 12 months. The mean tracheostomy dependence times for children with and without TCF were 33.1 and 23.4 months, respectively. Overall, 94 children (57.3%) developed a TCF. Conclusion To our knowledge, this study represents the largest collection of data for children who have been decannulated following tracheostomy placement. These data demonstrate that the risk of developing a TCF increases with longer tracheostomy dependence times in children. Level of Evidence 4. Laryngoscope, 2017

Background Vocal fold movement impairment (VFMI), a known complication following thoracic aortic surgery, has been associated with poorer surgical outcomes, including higher pulmonary complications and longer length of stay (LOS). Awake transcervical injection laryngoplasty in the inpatient setting serves to augment pulmonary toilet function for affected patients. This study investigates clinical outcomes of patients who underwent early versus late injection laryngoplasty following aortic surgery. Methods A 5-year review (2011–2016) of 35 patients who underwent inpatient injection laryngoplasty for VFMI following aortic repair was conducted. Data included demographics, surgery parameters, laryngologic evaluation, pulmonary complications, LOS, and mortality. Early injection was defined as within 5 days from extubation. Statistical analyses were performed using SPSS, version 17.0 (IBM Corp., Armonk, NY). Results All 35 patients (mean age 56, 77% male) underwent left vocal-fold injection laryngoplasty without complication. There were 15 (43%) early procedures and 20 (57%) late procedures. Mean LOS for early and late injection groups (13 vs. 20 days, respectively) significantly differed (P = 0.04, 95% confidence interval (CI) 0.3 to 14.4). Early laryngoplasty cohorts experienced less pulmonary complications (20%) than those who had late medialization (50%), but this did not reach significance (P = 0.06, 95% CI −0.3 to 8.1). The most common complication type in both groups was therapeutic bronchoscopy. Conclusion Early awake injection laryngoplasty within 5 days from extubation is feasible and may improve clinical outcomes for patients with VFMI following aortic repair. Further prospective studies on this approach for VFMI after thoracic surgery are needed. Level of Evidence 4. Laryngoscope, 00:000–000, 2017

Objective Vocal fold movement impairment (VFMI) due to neuronal injury occurs in 20% to 30% of surgeries in the region of the aortic arch. Early injection laryngoplasty can aid with postoperative pulmonary toilet in these high-risk cardiovascular patients. The purpose of this study is to determine whether continuing antiplatelet and anticoagulation therapy during awake transcervical injection laryngoplasty surgery is safe, and if there is any increase in bleeding complications in these patients. Methods This is a retrospective review of patients undergoing awake injection laryngoplasty surgery for VFMI between 2013 and 2016 at a tertiary academic center specializing in aortic and mediastinal diseases. Records were reviewed for patients regarding baseline antiplatelet or anticoagulation therapy, and whether these medications were stopped or continued preoperatively. The primary outcome was bleeding complications. Results Of the 95 surgeries reviewed, 44 (46%) were performed for patients on antiplatelet therapy, and 71 (75%) for patients on anticoagulation therapy. None of the patients on antiplatelet therapy had their treatment discontinued. Of the patients on anticoagulation, 13 (16.4%) had their therapy held prior to surgery. There was no observed difference in bleeding complications between patients who were continued on antiplatelet or anticoagulation treatment versus those whose therapy was withheld. Conclusion These results suggest that patients undergoing awake transcervical injection laryngoplasty for VFMI can be maintained on antiplatelet or anticoagulation therapy without increased risk of bleeding. Further larger studies are needed to confirm these findings. Level of evidence 4. Laryngoscope, 127:1850-1854, 2017.

Introduction Vocal fold movement impairment (VFMI) is a well-known sequela of cervical and thoracic procedures performed in the vicinity of the recurrent laryngeal nerve. Interpretation of flexible nasolaryngoscopy (FNL) can be difficult in young children due to crying, secretions, and obstructing supraglottic structures. We have previously published on the use of radiologist performed and interpreted, laryngeal ultrasound (LUS) to evaluate vocal fold mobility with substantial agreement with FNL in infants in the cardiovascular intensive care unit. The purpose of this study was to evaluate point of care, clinician performed, LUS for vocal fold mobility in a pediatric voice clinic. Methods LUS and FNL were performed and recorded on 30 consecutive patients (11 with a clinical diagnosis of VFMI and 19 with clinically normal mobility) in a pediatric voice clinic. All LUS was performed by a single clinician (reviewer 1) with a GE logiq P9 and 12 MHz linear probe. Deidentified recordings of the LUS and FNL (without sound) were reviewed in random order by 2 fellowship trained pediatric otolaryngologists who were blinded to the vocal fold mobility. Cohen's kappa was used to determine agreement. Results There was substantial agreement ( κ = 0.7) between the reviewers regarding interpretation of LUS as well as regarding interpretation of FNL κ = 0.7802. In addition, each reviewer had near perfect to substantial agreement between their interpretation of the LUS and FNL (reviewer 1 κ = 0.9294 and reviewer 2 κ = 0.8413). Conclusion Point of care, clinician performed, LUS can be used for the identification of VFMI with substantial agreement with FNL with good inter-rater reliability. This provides clinicians with another tool in their armamentarium for the evaluation of challenging larynges.

The objective of this study was to systematically review the literature regarding vocal fold motion impairment (VFMI), respiratory outcomes, and swallowing outcomes in children following congenital heart surgery (CHS).PubMed, Embase, Medline, and CINAHL databases.Data sources were searched from inception to November 30, 2018. Studies that described recovery of VFMI and swallowing function following CHS were included, and a qualitative analysis was performed.A total of 1371 studies were identified, of which 8 met inclusion criteria for VFMI and 5 met inclusion criteria for swallowing outcomes. Studies including patients who underwent isolate patent ductus arteriosus ligation were excluded. VFMI was present in 8% to 59% of subjects, and rates of recovery ranged from 9% to 96% at 6 months to 6 years of follow-up. Inability to maintain an oral diet occurred in 14% to 100% of subjects with VFMI and 11% to 61% without VFMI following surgery. Tolerance of an oral diet without tube feeding was present in 66% to 75% of subjects with VFMI and 88% to 100% without VFMI at 24 days to 3.2 years of follow-up. Limited data suggest that time to extubation is longer in VFMI subjects, but overall hospital length of stay and mortality may not be affected by VFMI status.Data evaluating dysphagia and VFMI after CHS are limited. Most studies suggest significant improvement in swallowing function, while rate of recovery of VFMI is variable. Future prospective studies with standardized screening and follow-up are needed to better elucidate outcomes to help develop algorithms for identification and management of VFMI after CHS.

OBJECTIVES Non-selective laryngeal reinnervation (NSLR) using the ansa cervicalis to the recurrent laryngeal nerve (RLN) is a promising treatment option for pediatric unilateral neuronal vocal fold movement impairment (VFMI). The aim is to describe our clinical outcomes with this technique and to identify preoperative characteristics that may predict postoperative voice outcomes. METHODS This is a cohort study of pediatric patients with unilateral neuronal VFMI, who underwent NSLR from March 2012 to July 2018. Pre- and postoperative Pediatric Voice Related Quality of Life (PVRQOL) questionnaires, Consensus Auditory Perceptual Evaluation of Voice (CAPE-V) ratings, and objective voice measures were obtained. In addition, patients underwent preoperative laryngeal electromyography (LEMG). RESULTS Thirty-two patients were identified. Twenty-one had complete data sets for analysis. The mean duration of VFMI was 9.02 years (range 1.1-26.1 years). There were significant improvements in PVRQOL (P = .0005), in all CAPE-V subsets (P ≤ .0001 to .0195), mean and maximum intensities (P = .0342 and 0.0110, respectively), cepstral peak prominence (P = .0001), and cepstral spectral index of dysphonia (P ≤ .0001). A worse preoperative LEMG correlated with a greater change in maximum phonation time (P = .0162) and maximum intensity (P = .0346). Age at injury and duration of injury had no significant impact on voice outcomes; however, patients with concurrent posterior glottic insufficiency did have smaller changes in PVRQOL (P = .012). CONCLUSION NSLR is an effective treatment for pediatric unilateral neuronal VFMI even many years after initial RLN injury. LEMG may help predict voice outcomes of reinnervation in pediatric patients, but further data is still needed. LEVEL OF EVIDENCE 4 Laryngoscope, 130:1525-1531, 2020.

Unilateral vocal fold movement impairment (VFMI) in infants and children may be due to congenital, iatrogenic, or idiopathic causes and can result in stridor, dysphagia, and/or dysphonia. As a result, these patients may have longer hospital length of stays, recurrent pulmonary infections, and/or impaired psychosocial functioning. Diagnosis may be delayed because glottic incompetence can be overshadowed by other comorbid conditions such as prematurity or congenital heart disease. Iatrogenic injury is the most common cause of VFMI due to the meandering route the recurrent laryngeal nerve takes through the neck and chest. Flexible nasolaryngoscopy is typically used to diagnose VFMI, but visualizing the larynx may be challenging due to patient cooperation or anatomic limitations. Transcervical laryngeal ultrasound can be used as another means of assessing vocal fold mobility. Spontaneous vocal fold movement recovery or vocal fold compensation is frequently seen but may take months or even years to achieve. Treatment options for persistent VFMI include voice therapy, injection laryngoplasty, laryngeal framework surgery, and laryngeal reinnervation. Each of these modalities has its own advantages and disadvantages, and each may be applied in isolation or combination.

ObjectiveThis project compares the degree of tracheal collapse determined by rigid and flexible bronchoscopy in paediatric patients with tracheomalacia.MethodsA total of nine patients with tracheomalacia underwent both rigid and flexible video bronchoscopy. All patients were breathing spontaneously. Cross-sectional images of the airway were processed using the ImageJ program and analysed via colour histogram mode technique in order to delineate the luminal area. Paired t-tests (conducted using Stata software version 13.0) quantified differences between rigid and flexible bronchoscopes regarding the ratios of luminal pixels at maximum airway collapse to expansion. Correlation between both techniques in terms of airway collapse to expansion ratios was determined by calculating the Pearson correlation coefficient (R).ResultsThe difference in ratios of maximum collapse to expansion between rigid and flexible bronchoscopy was not statistically significant (p = 0.4656) and was positively correlated (R = 0.523).ConclusionThe ratios suggest that rigid and flexible bronchoscopy are equally efficacious in assessing tracheomalacia severity, and may be used interchangeably in a clinical setting.