Blue light laser recontouring for pediatric benign fibrovascular vocal fold lesions.

INTRODUCTION: Up to 40% of children with hoarseness due to benign fibrovascular vocal fold lesions do not respond to voice therapy and could benefit from further intervention to improve their communication abilities. Currently there are limited surgical options for children too young to comply with post-operative voice rest. We have begun using the 445 nm laser to recontour benign fibrovascular vocal fold lesions without post-operative voice rest in young children with hoarseness due to vocal fold nodules that is unresponsive to voice therapy. This report presents pilot data on the effect of this treatment on pediatric voice-related quality of life. METHODS: Pediatric patients with benign fibrovascular lesions and severe subjective dysphonia (per parents or teachers) were given the option of undergoing surgery or continuing voice therapy. Those that opted for surgery underwent 445 nm laser recontouring of their vocal folds. They were discharged home the same day with no voice rest required. Pre- and post-demographic, acoustic measures, auditory perceptual assessments, and validated patient quality of life measures were collected. RESULTS: Four patients (ages 3-8y, all male) were selected for surgery. The mean pre- and post-op PVRQOL scores were 59.4 (range: 22.5-80) and 98.1 (range: 97.5-100), respectively (low scores suggest lower voice-related QOL), and a mean change of 38.8 (previously established minimum clinically important difference: 12). Pre- and post-acoustic and aerodynamic measures similarly reflected this improvement. CONCLUSION: This pilot case series addresses a commonly seen population (children with benign fibrovascular lesions and significant dysphonia despite voice therapy) where the best practice for timing and types of surgical intervention is unclear. Photoangiolytic lasers (including the 445 nm laser) are gaining popularity for the treatment of benign laryngeal pathologies, and their use may expand treatment possibilities for children with severe dysphonia due to benign vocal fold lesions that do not respond to voice therapy. Further longitudinal investigations are necessary to confirm the safety and efficacy.

Development and Content Validity of a Novel Patient-Reported Outcome Measure for Total Laryngectomy: The LARY-Q.

OBJECTIVES: To develop a patient-reported outcomes measure (PROM) for total laryngectomy. STUDY DESIGN: Qualitative interviews with a purposive sample of patients with total laryngectomy, followed by cognitive debriefing interviews with patients and expert feedback. METHODS: Concept elicitation was performed using in-depth qualitative interviews with a purposive sample of patients who had undergone total laryngectomy. Patients were recruited from head and neck surgery and speech-language pathology clinics as well as via laryngectomy support groups. Interviews were conducted, recorded, transcribed, and coded, resulting in a conceptual framework and item pool. Using the item pool, preliminary scales were drafted. The scales were revised iteratively over 5 rounds using feedback from cognitive interviews with patients and multi-institutional and multi-disciplinary expert feedback. RESULTS: A total of 15 patients with total laryngectomy (mean age 68 years, range 57-79) were interviewed resulting in 1555 codes. The codes were used to form a conceptual framework grouped into top-level domains of stoma, function, health-related quality of life, devices, and experience of care. Items were used to form 15 preliminary scales that were revised over five rounds of cognitive debriefing interviews (n = 9 patients) and expert feedback (n = 17 experts). The field-test version of the LARY-Q has 18 scales and 277 items in total. CONCLUSIONS: The LARY-Q is a novel PROM designed to assess outcomes associated with total laryngectomy. The next step involves a field test study with a heterogenous sample of patients to assess the psychometric properties of the LARY-Q and perform item reduction.

Cost-effectiveness analysis of using the heat and moisture exchangers compared with alternative stoma covers in laryngectomy rehabilitation: US perspective.

BACKGROUND: This study aims to evaluate the cost-effectiveness of using heat and moisture exchangers (HMEs) vs alternative stoma covers (ASCs) following laryngectomy in the United States. METHODS: A cost-effectiveness and budget impact analysis were conducted including uncertainty analyses using real-world survey data with pulmonary events and productivity loss. RESULTS: HME use was more effective and less costly compared with ASCs. Quality-adjusted life years were slightly higher for HME-users. Total costs per patient (lifetime) were $59 362 (HME) and $102 416 (ASC). Pulmonary events and productivity loss occurred more frequently in the ASC-users. Annual budget savings were up to $40 183 593. Costs per pulmonary event averted were $3770. CONCLUSIONS: HME utilization in laryngectomy patients was cost-effective. Reimbursement of HME devices is thus recommended. Utilities may be underestimated due to the generic utility instrument used and sample size. Therefore, we recommend development of a disease-specific utility tool to incorporate in future analyses.

Perceptual Clinical Features in Exercise-Induced Laryngeal Obstruction (EILO): Toward Improved Diagnostic Approaches.

INTRODUCTION: Athletes with exercise-induced laryngeal obstruction (EILO) (previously commonly referred to as paradoxical vocal fold motion disorder, or paradoxical vocal fold motion, among other terms) are often misdiagnosed, resulting in prolonged, and at times inappropriate, clinical management. The high prevalence of misdiagnosis is largely due to a lack of universal consensus of key clinical features indicating EILO and a dearth of validated quantitative approaches to accurately detect episodic laryngeal breathing disorders (ELBD) from other pathologies. Additionally, mechanisms underlying EILO clinical presentation are poorly understood, further confounding identification and management of the condition. Therefore, the objectives of this study were twofold. The first was to identify patient-centered perception of symptoms that could distinguish adolescent athletes with EILO from athletes without the condition, at baseline (rest) and during an exercise challenge (provocation), and to quantify symptom severities for use as preliminary diagnostic benchmarks. The second objective was to investigate the merit of one commonly proposed mechanism in the EILO literature-stress reactivity (temperament)-by comparing personality traits in athletes with and without EILO. METHODS: Twelve (12) athletes diagnosed with EILO and 14 healthy athletic volunteers without the condition were asked to rate the severity of their present symptoms using a 0-100 continuous visual analog scale. Participants then underwent an exercise challenge with simultaneous laryngoscopy and were asked to complete the same set of symptom severity ratings experienced during rigorous exercise. Finally, participants completed the Fear subscale on the early adolescent temperament questionnaire-revised (EATQ-R) to measure self-perceived levels of stress reactivity. RESULTS: There were significant group differences for inspiratory and expiratory dyspnea with exercise (P = 0.01). Symptoms of stridor (EILO: P = .01; control: P = .001) and throat tightness (EILO: P = .01, control: P = .01) were statistically different between rest and exercise in both groups. However, no group differences were found on these two parameters (P > .05). Other symptoms from the list of previously purported symptoms indicative of ELBD (e.g. cough, dysphonia) were infrequently reported in the exercise variant. Additionally, measurements of stress reactivity on the EATQ-R Fear subscale were similar between the two athletic groups. Interestingly, EATQ-R Fear Subscale scores for both groups were significantly higher compared to typical adolescents in the U.S. population (P < .001, respectively). DISCUSSION: Results suggest dyspnea severity, particularly when experienced during an exercise-induced ELBD (EILO) episode, is the most sensitive symptom parameter to distinguish individuals with EILO from those without the condition. These findings confirm previous literature describing episodic laryngeal breathing disorders in clinical cohorts. Results also showed symptoms of throat tightness and stridor is more prevalent during exercise, compared to rest. However, the level of their severity occurred variably across both groups of athletes and may point to a less robust indication of pathology. Finally, similarities to stress reactivity between the two athletic groups imply certain temperaments historically attributed to patients with EILO may instead better reflect temperaments in competitive young athletes, in general. CONCLUSION: Study findings highlight the importance of using normative comparisons in the study of episodic laryngeal breathing disorders to prevent overgeneralization of characteristics to clinical cohorts. Results also speak of the clinical utility of exercise challenge to improve specificity of EILO diagnosis.

State of the art: Rehabilitation of speech and swallowing after total laryngectomy.

Despite the development and expansion of non-surgical organ preservation therapy, total laryngectomy continues to be the optimal therapy for far-advanced local disease and the only curative option for radiotherapy failures not amenable to partial laryngeal procedures. Laryngectomy, however, remains a life-altering operation with profound effects on swallowing and speech. In the nearly 150 years since the first total laryngectomy was performed, few ablative aspects have changed, but reconstructive techniques have undergone radical evolution. This review will trace the origins of laryngeal rehabilitation for voice and swallowing, the current state of the art with attention to pre-treatment considerations and post-operative management, current surgical management techniques, and the future of functional laryngeal reconstruction.

The Study of Laryngoscopic and Autonomic Patterns in Exercise-Induced Laryngeal Obstruction.

OBJECTIVES: (1) Identify laryngeal patterns axiomatic to exercise-induced laryngeal obstruction (EILO) and (2) investigate the role of autonomic function in EILO. METHODS: Twenty-seven athletic adolescents (13 EILO, 14 control) underwent laryngoscopy at rest and exercise. Glottal configurations, supraglottic dynamics, systolic blood pressure responses, and heart rate recovery were compared between conditions and groups. RESULTS: Inspiratory glottal angles were smaller in the EILO group than the control group with exercise. However, group differences were not statistically significant ( P > .05), likely due to high variability of laryngeal responses in the EILO group. Expiratory glottal patterns showed statistically greater abductory responses to exercise in the control group ( P = .001) but not the EILO group ( P > .05). Arytenoid prolapse occurred variably in both groups. Systolic blood pressure responses to exercise were higher in the control group, and heart rate recovery was faster in the EILO group. However, no significant differences were seen between the 2 groups on either autonomic parameter ( P > .05). CONCLUSIONS: "Paradoxical" inspiratory and blunted expiratory vocal fold pattern responses to exercise best characterize EILO. Group differences were only seen with exercise challenge, thus highlighting the utility of provocation and control groups to identify EILO.

Indirect vs Direct Voice Therapy for Children With Vocal Nodules: A Randomized Clinical Trial.

Importance: Benign vocal fold nodules affect 12% to 22% of the pediatric population, and 95% of otolaryngologists recommend voice therapy as treatment. However, no randomized clinical trials that we are aware of have shown its benefits. Objective: To determine the impact of voice therapy in children with vocal fold nodules according to pretherapy and posttherapy scores on the Pediatric Voice-Related Quality of Life (PVRQOL) survey; secondary objectives included changes in phonatory parameters. Design, Setting, and Participants: For this multicenter randomized clinical trial, 114 children ages 6 to 10 years with vocal fold nodules, PVRQOL scores less than 87.5, and dysphonia for longer than 12 weeks were recruited from outpatient voice and speech clinics. This age range was identified because these patients have not experienced pubertal changes of the larynx, tolerate stroboscopy, and cooperate with voice therapy. Participants were blinded to treatment arm. Interventions: Participants received either indirect or direct therapy for 8 to 12 weeks. Indirect therapy focused on education and discussion of voice principles, while direct treatment used the stimulus, response, antecedent paradigm. Main Outcomes and Measures: The primary outcome measure was PVRQOL score change before and after treatment. Secondary phonatory measures were also compared. Results: Overall, 114 children were recruited for study (mean [SD] age, 8 [1.4] years; 83 males [73%]); with 57 randomized to receive either indirect or direct therapy. Both direct and indirect therapy approaches showed significant differences in PVRQOL scores pretherapy to posttherapy. The mean increase in PVRQOL score for direct therapy was 19.2, and 14.7 for indirect therapy (difference, 4.5; 95.3% CI, -10.8 to 19.8). Of 44 participants in the direct therapy group, 27 (61%) achieved a clinically meaningful PVRQOL improvement, compared with 26 of 49 (53%) for indirect therapy (difference, 8%; 95% CI, -12 to 28). Post hoc stratification showed robust effects in the direct therapy group for older children (Cohen d = 0.50) and the latter two-thirds of participants (Cohen d = 0.46). Vocal fold nodules reduced in size in 31% (22 of 70) and completely resolved in 11% (8 of 70) of participants who consented to a second set of images after going through the recruitment process. Conclusions and Relevance: Both direct and indirect voice therapy improved voice-related quality of life in children with vocal fold nodules, although there was no significant difference between approaches. Future studies may focus upon which voice therapy approaches are effective in treating age-defined populations. Trial Registration: clinicaltrials.gov Identifier: NCT01255735.

The Effect of Initial Tracheoesophageal Voice Prosthesis Size on Postoperative Complications and Voice Outcomes.

OBJECTIVES: The optimal initial size of tracheoesophageal voice prosthesis (TEVP) for tracheoesophageal voice restoration (TEVR) remains unclear. As purported advantages exist favoring the placement of both 16F and 20F prostheses, this study compares complications and voicing outcomes after placement of 16 and 20 French (F) prostheses. METHODS: All cases of TEVR at an academic medical center were retrospectively reviewed (2007-2013). Complications including dislodgement, leakage, infection, and granulation tissue were compared. Outcomes including frequency of prosthesis change, acquisition of speech, and time to fluent speech were compared. RESULTS: Of 47 patients, 25 received 20F prostheses, and 22 received 16F. Postoperative complications were similar between groups, including leakage around the prosthesis (P = .373) and aspiration pneumonia (P = .670). There were no significant differences in timing of voicing or ability to achieve fluency. Although the 20F group appeared to undergo fewer prostheses changes per year (3.0 vs 5.3) and had a longer duration of use before first prosthesis change (76 vs 43 days), neither difference was found to be statistically significant. CONCLUSION: Voice restoration was successfully achieved using either 16F or 20F prostheses. Prosthesis diameter did not significantly affect complications or voicing. Both prostheses may be placed with safety and efficacy, allowing the practitioner to choose based on the potential individual benefits of either device.

Tracheoesophageal voice after total laryngopharyngectomy reconstruction: Jejunum versus radial forearm free flap.

OBJECTIVE/HYPOTHESIS: Tracheoesophageal (TE) voice restoration after laryngopharyngectomy with jejunal (Jej) flap and radial forearm flap (RFF) reconstruction has been successfully completed and studied for both techniques, but no direct comparisons exist. We undertook this study to directly compare TE voice in patients with total laryngopharyngectomy (TLP) reconstruction using the Jej and the RFF in a comprehensive and rigorous manner. STUDY DESIGN: Retrospective cohort study. METHODS: Forty patients after total laryngectomy or TLP were grouped by pharyngeal closure method: 18 primary closure (STL), 10 jejunal flap (TLP-Jej), and 12 radial forearm flap (TLP-RFF). Voice recordings underwent objective acoustic analysis and blinded subjective assessment by trained and naïve listeners. Quality-of-life (QOL) assessments were obtained in all subjects using general health, disease-specific, and voice-specific survey tools. RESULTS: All studies groups had similar demographics. Acoustic analysis demonstrated no differences in fundamental frequency or intensity levels. Subjective assessment demonstrated statistically significant inferior voice function of the reconstructed patients (TLP-Jej and TLP-RFF) compared to STL subjects for nearly all parameters tested by both naïve and trained listeners. No differences were noted between TLP-Jej and TLP-RFF subjects for any of the parameters evaluated. Overall, trained listeners assessed TE voice more favorably compared to naïve listeners in a significant manner. The three QOL surveys revealed no significant differences between TLP-Jej and TLP-RFF subjects. CONCLUSION: Tracheoesophageal voice in TLP-Jej and TLP-RFF subjects was equivalent but inferior to STL subjects. Reconstructed subjects had no differences in general, disease-specific, and voice-specific quality of life. LEVEL OF EVIDENCE: 2b.

Placement of a 16-French voice prosthesis at the time of secondary tracheoesophageal voice restoration.

PURPOSE: Tracheoesophageal voice restoration (TEVR) has traditionally been described with fistula tract creation, catheter placement, and prosthesis placement. Prosthesis placement at the time of tracheoesophageal puncture (TEP) utilizing 20-French prostheses has been previously described. Smaller initial prostheses may allow fluent speech with reduced long-term complications, such as widening of the fistula and peri-prosthesis leakage. This study evaluates the safety and efficacy of the 16-French prostheses placement at the time of secondary TEP. METHODS: All cases of 16-French tracheoesophageal voice prosthesis (TEVP) placement at the time of secondary TEP were reviewed from 1/2011 through 12/2013 at a large academic medical center. Perioperative complications attributable to device placement were recorded, including inability to place prosthesis, intraoperative complications, post-operative infection, prosthesis dislodgement, prosthesis leakage, and inability to obtain voice. RESULTS: Twenty-one patients received placement of a 16-French TEVP at the time of secondary TEP. All prostheses were placed without intraoperative complications. The proportion of patients who had minor complications within the first postoperative month was 23.8%, including leakage through the prosthesis (3 of 21), granulation tissue near the prosthesis (1 of 21), retained sheath (1 of 21) and prosthesis displacement (1 of 21). Leakage and displacement were addressed with change and replacement, respectively. Fluent voicing was achieved in 85.7% patients, with a median time to voicing of 18.5days. CONCLUSIONS: Placement of 16-French TEVPs is effective and safe, with an acceptable rate of minor complications attributable to the prosthesis. Therefore, a smaller prosthesis may be primarily placed at the time of secondary TEP and is our preference.

Establishment of a normative cepstral pediatric acoustic database.

IMPORTANCE: Few studies have used objective measures to evaluate the development of the normal pediatric voice. Cepstral analysis of continuous speech samples is a reliable method for gathering acoustic data; however, it has not been used to examine the changes that occur with voice development. OBJECTIVE: To establish and characterize acoustic patterns of the normal pediatric voice using cepstral analysis of voice samples from a normal pediatric voice database. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional study of 218 children aged 4 to 17 years, for whom English was the primary language spoken at home, conducted at a pediatric otolaryngology practice and pediatric practice in a tertiary hospital (April 2012-May 2014). INTERVENTIONS AND EXPOSURES: Sustained vowel utterances and continuous speech samples (4 Consensus Auditory-Perceptual Evaluation of Voice [CAPE-V] and 2 sentences from the rainbow passage) were recorded and analyzed from children with normal voices. MAIN OUTCOMES AND MEASURES: Normal values were collected for the acoustic measures studied (ie, fundamental frequency, cepstral peak fundamental frequency, cepstral peak prominence [CPP], low-to-high spectral ratio [L/H ratio], and cepstral-spectral index of dysphonia in recorded phrases) and compiled into a normative acoustic database. RESULTS: Significant changes in fundamental frequency were observed with a distinct shift in slope at ages 11 and 14 years in boys for sustained vowel (ages 4-11 years, -6.83 Hz/y [P < .001]; 11-14 years, -27.62 Hz/y [P < .001]; and 14-17 years, -5.68 Hz/y [P = .001]), all voiced (ages 4-11 years, -4.19 Hz/y [P = .002]; 11-14 years, -29.42 Hz/y [P < .001]; and 14-17 years, -4.63 Hz/y [P < .001]), glottal attack (ages 4-11 years, -4.51 Hz/y; 11-14 years, -27.23 Hz/y; and 14-17 years, -1.70 Hz/y [P < .001 for all]), and rainbow (ages <14 years, -20.68 Hz/y [P < .001]; and 14-17 years, -4.50 Hz/y [P = .001]) recordings. A decreasing linear trend in fundamental frequency among all recordings (vowel, all voiced, easy onset, glottal attack, plosives, and rainbow) was found in girls (-2.56 Hz/y [P < .001], -3.48 Hz/y [P < .001], -2.82 Hz/y [P < .001], -3.49 Hz/y [P < .001], -2.30 Hz/y [P < .001], and -2.98 Hz/y [P = .01], respectively). A linear increase in CPP was seen with age in boys, with significant changes seen in recordings for vowel (0.10 dB/y [P = .05]), all voiced (0.2 dB/y [P < .001]), easy onset (0.13 dB/y [P < .001]), glottal attack (0.12 dB/y [P < .001]), plosives (0.15 dB/y [P < .001]), and rainbow (0.17 dB/y [P = .006]). A significant linear increase in CPP for girls was only seen in all voiced (0.13 dB/y [P < .001]). L/H ratio showed a linear increase with age among all speech samples (vowel, all voiced, easy onset, glottal attack, plosives, and rainbow) in boys (1.14 dB/y [P < .001], 0.92 dB/y [P < .001], 1.19 dB/y [P < .001], 0.79 dB/y [P < .001], 0.69 dB/y [P < .001], and 0.54 dB/y [P = .002], respectively) and girls (0.96 dB/y, 0.60 dB/y, 0.75 dB/y, 0.37 dB/y, 0.44 dB/y, and 0.58 dB/y, respectively [P ≤ .001 for all]). CONCLUSIONS AND RELEVANCE: This represents the first pediatric voice database using frequency-based acoustic measures. Our goal was to characterize the changes that occur in both male and female voices as children age. These findings help illustrate how acoustic measurements change with development and may aid in our understanding of the developing voice, pathologic changes, and response to treatment.

Pediatric voice analysis: comparison of 2 computerized analysis systems.

IMPORTANCE: This research contributes to the pediatric objective voice measurement database while identifying comparable measurements between 2 available voice analysis systems. OBJECTIVE: To compare selective normative pediatric acoustic variables between the Multi-Dimensional Voice Program (MDVP) and the Voice Evaluation Suite (VES) computerized voice analysis systems. Additionally, it describes the first comprehensive pediatric database analyzing fundamental frequency, jitter, shimmer, and noise to harmonic ratio using the VES. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional study with planned data collection conducted at a tertiary referral otolaryngologic clinic. Participants were 335 children, aged 4 to 18 years, with normal voices. INTERVENTIONS: Objective voice data were collected on the MDVP and the VES systems. MAIN OUTCOMES AND MEASURES: Fundamental frequency, jitter, shimmer, and noise to harmonic ratio. RESULTS: The fundamental frequencies agreed with previous pediatric normative values. There was not a statistically significant difference between MDVP and VES measurements of mean fundamental frequency (P = .23). Jitter percentage (P < .001), shimmer percentage (P < .001), and noise to harmonic ratio (P < .002) for all children were statistically different between the 2 voice evaluation systems. CONCLUSIONS AND RELEVANCE: These data show that the measured fundamental frequency of normal voices in children is comparable between the MDVP and VES voice analysis systems. Jitter, shimmer, and noise to harmonic ratio values are not interchangeable between voice analysis systems. The voice analysis system should be reported when providing voice measurement outcomes in the literature.

Consistency of voice frequency and perturbation measures in children.

OBJECTIVE: Evaluate normal pediatric voice frequency and perturbation measures with Voice Evaluation Suite (VES) and Multi Dimensional Voice Program (MDVP), determine the consistency of these measures over time, and understand which measures might be most useful for evaluating children with voice disorders. STUDY DESIGN: Prospective, longitudinal study of normal voices of 50 children aged 4 to 17 years. SETTING: Pediatric otolaryngology clinic within tertiary hospital. SUBJECTS AND METHODS: Two tests of sustained utterances from each child were evaluated by 2 computerized voice analysis programs for frequency and perturbation. Intraclass correlation coefficient (ICC) was used to assess the reliability between the samples. RESULTS: Children (male/female, 1.08:1) with a mean age of 8.34 years were tested on an average of 54.2 minutes apart. Each test included 4 utterances; 1 was analyzed by MDVP, and 3 grouped utterances were averaged and evaluated by VES. Fundamental frequency had excellent reliability (ICC = 0.95) in both VES and MDVP. Jitter, shimmer, and noise to harmonic ratio were poorly reliable (ICC ≤ 0.4) in MDVP but had good to excellent reliability (ICC 0.66-0.8) in VES. CONCLUSION: Single, sustained utterances in children provide consistent measures of frequency. Perturbation is not reliably measured by such testing, but averaging multiple samples yields improved consistency. Evaluating acoustic measure stability in spontaneous speech and in sustained utterances cued by a tuning frequency can provide further insight on pediatric voice consistency.

Establishment of a normative pediatric acoustic database.

OBJECTIVES To establish a normative pediatric acoustic database and to analyze the acoustic characteristics of the age groups studied. DESIGN Prospective gathering of acoustic parameters on healthy children aged 4 to 18 years. SETTING An outpatient pediatric otolaryngology clinic. PATIENTS A total of 335 children (165 girls and 170 boys) were evaluated. MAIN OUTCOME MEASURES Normative values were obtained for the acoustic parameters studied. RESULTS Discrete fundamental frequency changes occurred at ages 11 and 14 years in girls and ages 12 and 16 years in boys. Values for jitter percentage, shimmer percentage, and noise to harmonic ratio fell within the normative thresholds of adult values. CONCLUSIONS This is the largest pediatric computerized voice analysis database in the English language. This database has been designed to develop an age- and sex-based growth chart to track the developing pediatric voice as it changes with maturation. A distinct vocal profile of girls and boys is evident, with key changes noted at critical periods of development and with significant differences among fundamental frequency between and within sexes. A comprehensive database can be used to help aid future voice therapy and phonosurgical strategies and provide the foundation for future studies into the development of the pediatric voice as it matures into adulthood.

Pediatric laryngeal diadochokinetic rates: establishing a normative database.

OBJECTIVE: Laryngeal diadochokinetic (L-DDK) rate is a measure of laryngeal neural integrity. The objectives for this study included the following: (1) establish the first comprehensive pediatric normative database for L-DDK rates (DDK) using the Voice Evaluation Suite, a computerized voice analysis program; and (2) analyze normal L-DDK rates for age and gender differences. STUDY DESIGN: Cross-sectional study with planned data collection. SETTING: Outpatient pediatric otolaryngology clinic. SUBJECTS AND METHODS: Three hundred seven children aged 4 to 18 with normal voices. L-DDK rates were collected during a 6-month period. Main outcome measures included age, gender, and L-DDK rates. RESULTS: Three hundred seven children (151 girls and 156 boys) were evaluated. There was no statistically significant difference between the overall mean L-DDK rate of boys (2.69 syllables/s) compared to girls (2.55 syllables/s; P > .05). Further analysis of all individual age groups did not reveal any statistical significance between boys and girls. There was a statistically significant difference among children aged 4 to 11 compared to those 12 to 18 years old. Among boys aged 4 to 11, the mean rate was 2.49 syllables per second, whereas among 12- to 18-year-olds, the rate was 2.95 syllables per second (P < .01). The mean rate was 2.40 syllables per second among girls aged 4 to 11 and 2.74 syllables per second for those aged 12 to 18 (P < .01). CONCLUSION: This is the largest normative pediatric L-DDK analysis in the English literature. The findings suggest that neurolaryngeal development approaches adult maturation at the beginning of the teenage years. These data have the potential application for objective measurement of neurolaryngeal coordination in children with neurologic impairment and also in children who have undergone nerve reinnervation procedures.

Pediatric paradoxical vocal-fold motion: presentation and natural history.

OBJECTIVES: To describe (1) a cohort of children with paradoxical vocal-fold motion (PVFM) who were referred to a multidisciplinary airway center and (2) the outcomes of various treatment modalities including speech therapy, gastroesophageal reflux disease treatment, and psychiatric treatment. PATIENTS AND METHODS: This was a case series with chart review of children younger than 18 years with PVFM evaluated at a tertiary care pediatric airway center over a 36-month period. RESULTS: Fifty-nine children with PVFM were evaluated. The cohort had a mean age of 13.64 years (range: 8-18 years) and a female-to-male ratio of 3:1. Speech therapy as an initial treatment resulted in a 63% (24 of 38) success rate after an average of 3.7 treatment sessions. Speech therapy was a more successful treatment than antireflux therapy (P = .001). Ten percent (6 of 59) of the children presented with a known psychiatric diagnosis, and 30% (18 of 59) of children in the cohort were ultimately diagnosed with a psychiatric condition. Children with inspiratory stridor at rest had a lower initial success rate with speech therapy (56%), a higher rate of underlying psychiatric disorders (75%), and a high rate of success after psychiatric treatment (100%) that required, on average, 3 sessions over a 2-month period. CONCLUSIONS: To our knowledge, this is the largest study to date on pediatric PVFM. The majority of children with PVFM improve with speech therapy. Children with PVFM at rest may be better treated with psychiatric therapy than speech therapy. Furthermore, children who present with symptoms at rest may have a higher likelihood of underlying psychiatric disease.

Simplified technique of tracheoesophageal prosthesis placement at the time of secondary tracheoesophageal puncture (TEP).

OBJECTIVES: Secondary tracheoesophageal (TE) puncture standardly involves placement of a catheter at time of TE fistula creation. We explore the feasibility of placement of the prosthesis at the time of TE puncture (TEP) obviating the need for a subsequent procedure to place the prosthesis. We describe the technique and evaluate the success and potential advantages. STUDY DESIGN: Retrospective chart review of consecutive patients who underwent TE prosthesis placement at the time of secondary TEP from 3/2009 to 1/2011. METHODS: Fourteen patients underwent the primary TE prosthesis placement at the time of secondary puncture and were evaluated. Assessed outcomes included patient demographics, success of prosthesis placement, need for repeat procedure, early or late prosthesis dislodgement, complications, and specific voice outcomes. RESULTS: Patient cohort included nine males, five females, with average age of 64 years. All TE prosthesis placements were successful. The 12-mm 20 F Blom-Singer Indwelling prosthesis was used in all cases. No complications occurred during prosthesis placement. Two perioperative complications occurred: one case of transient pulmonary edema from general anesthesia, one case of posterior tracheal wall swelling. The second was addressed with placement of a larger prosthesis. All patients successfully achieved good voice at an average of 4 days after the procedure (range: 1-9 days). CONCLUSIONS: This initial series of 14 consecutive patients demonstrates successful TE prosthesis placement at the time of secondary TE puncture. Functional voice was achieved in all patients with no significant immediate complications. No dislodgements occurred and no repeat procedures were required. Voice acquisition was achieved at an earlier time (4 days on average) than with traditional techniques and without the necessity of a subsequent procedure. Primary prosthesis placement at the time of secondary TE puncture is a successful option for surgical voice restoration with distinct advantages and minimal complications.

Evaluation of voice prosthesis placement at the time of primary tracheoesophageal puncture with total laryngectomy.

OBJECTIVES/HYPOTHESIS: Primary tracheoesophageal puncture (TEP) is a well-described and accepted method of surgical voice restoration and is standardly completed with a catheter placement intraoperatively, which is replaced with a prosthesis at a later date. This study evaluates the intraoperative placement of the voice prosthesis at the time of the primary TEP in an effort to understand the potential advantages and disadvantages of voice prosthesis placement at the time of primary TEP completed in conjunction with total laryngectomy. STUDY DESIGN: Retrospective chart review within an academic medical center. METHODS: After approval by the institutional review board of the Massachusetts Eye and Ear Infirmary, a retrospective chart review was completed of all cases of primary tracheoesophageal prosthesis placement completed in conjunction with primary tracheoesophageal puncture performed at the time of total laryngectomy. RESULTS: Thirty patients were identified, 29 of whom underwent laryngectomy for advanced laryngeal carcinoma. Twenty-eight of 29 patients received preoperative full-dose radiation therapy. Twenty-nine of 30 patients had a 20F classic Indwelling Blom-Singer prosthesis (InHealth Technologies, Carpinteria, CA) placed. One had placement of 16F Indwelling Blom-Singer prosthesis. No complications were noted with intraoperative prosthesis placement. No prostheses were dislodged in the postoperative period. Twenty-nine of 30 subjects had initial success with tracheoesophageal voice production. At 1-year follow-up, 23/30 subjects (77%) had successful voice restoration. Five failed because of recurrent disease, one subject never achieved successful voice, and one subject wanted the prosthesis removed although successful voice was achieved. Twenty-three of 25 (92%) disease-free subjects had functional voice restoration at 1-year post-total laryngectomy and primary prosthesis placement. CONCLUSIONS: This study demonstrates that the voice prosthesis can be safely and effectively placed intraoperatively at the time of primary TEP and laryngectomy. Initial voice acquisition rates were high and long-term success was well within the acceptable range.

Voice following laryngeal cancer surgery: troubleshooting common problems after tracheoesophageal voice restoration.

The introduction of tracheoesophageal voice restoration by Blom and Singer has provided laryngectomy patients with a successful alternative to the use of artificial larynx and esophageal speech. Although this method of communication provides for the rapid acquisition of intelligible, functional speech, there are common problems that may occur in these patients. Close follow-up of patients postoperatively along with thorough patient education is beneficial to improving long-term success with tracheoesophageal speech. The purpose of this article is to discuss common problems encountered in the treatment of patients who have undergone tracheoesophageal puncture and to provide systematic assessment and treatment guidelines that are essential to maintaining functional tracheoesophageal speech.