Type 1 laryngeal cleft: a multidimensional management algorithm.

IMPORTANCE: Early diagnosis and assessment in children with type 1 laryngeal cleft are essential in preventing aspiration and associated comorbidity. Appropriate use of conservative and surgical interventions in an evidence-based management strategy can improve overall outcome. OBJECTIVE: To evaluate the management of care for children with type 1 laryngeal cleft in our practice and develop an updated management algorithm. DESIGN, SETTING, AND PARTICIPANTS: We performed a review of medical records at a tertiary pediatric aerodigestive center. During a period of 7 years (July 18, 2005, to July 18, 2012), 1014 children younger than 18 years were evaluated for aspiration, choking, cough, or recurrent pneumonia. Of these, 44 children (4.3%) had a type 1 laryngeal cleft. Two were lost to follow-up; thus, 42 children were included in our final sample (28 males, 14 females). INTERVENTIONS: The care of 15 patients (36%) was managed conservatively, and 27 patients (64%) underwent endoscopic surgical repair of their laryngeal cleft. MAIN OUTCOME AND MEASURE: Assessment of our current management strategy. RESULTS: Success was defined as improving when a child was able to tolerate a feeding without aspirating or resolved when the child had transitioned to tolerating thin liquids. All patients received a trial of conservative therapy. Fifteen of the 42 patients (36%) had an anatomic cleft and were able to maintain the feeding regimen; thus, conservative treatment was successful in this group. The remaining 27 patients (64%) received surgical intervention. Overall operative success rate was 21 of the 27 patients (78%). The age of the child (P < .01) and comorbid conditions (P < .001) affected the outcomes of conservative measures and surgical repair. Only 6 patients did not demonstrate resolution, 5 of whom had significant comorbidities. CONCLUSIONS AND RELEVANCE: Age, comorbidity status, severity of aspiration, and the ability to tolerate a feeding regimen should be taken into account when deciding on conservative or surgical management for children with a type 1 laryngeal cleft. A clinical pathway for conservative and surgical management is presented.

Modified superior pharyngeal flap for the treatment of velopharyngeal insufficiency in children.

OBJECTIVE: To describe a modified rolled superior pharyngeal flap for treatment of velopharyngeal insufficiency (VPI) in children. METHODS: Prospective case series at a tertiary care multidisciplinary aerodigestive center. Four children, aged 5-12 years, with VPI refractory to speech therapy resulting after cleft palate (bilateral, submucous, or soft palate only) repair, failed traditional superior pharyngeal flap, fine motor incoordination, or adenoidectomy were studied. All 4 children underwent surgery with a modified superior pharyngeal flap, where aspects of the most commonly employed pharyngeal flap designs were combined to achieve the benefits of each technique and to allow for mucosal covering on either side of the flap, improved control of the lateral port size due to the horizontal-to-horizontal inset technique, and the ability to avoid a vertical or horizontal split in a previously repaired cleft palate. RESULTS: All 4 patients demonstrated resolution of their VPI as measured by subjective and/or objective criteria. Every patient required additional speech therapy postoperatively. CONCLUSIONS: Our modified superior pharyngeal flap technique may be a good option in patients with small velopharyngeal gaps undergoing revision velopharyngeal surgery. A larger, longitudinal study would better address the overall outcomes of this technique.

Cine magnetic resonance imaging with simultaneous audio to evaluate pediatric velopharyngeal insufficiency.

OBJECTIVE: To develop a protocol linking cine magnetic resonance (MR) imaging to simultaneously acquired audio recordings of specific phonatory tasks to evaluate velopharyngeal insufficiency (VPI) in children. DESIGN: Institutional review board-approved development and application of a novel dynamic cine MR imaging protocol linked to simultaneously recorded audio. SETTING: A tertiary care multidisciplinary pediatric airway center. PARTICIPANTS: Three healthy adult volunteers and 5 pediatric volunteers (age range, 9.3-18.9 years; mean age, 12.4 years) from the multidisciplinary pediatric airway center with VPI who previously had undergone nasopharyngoscopy, videofluoroscopy, or both. INTERVENTIONS: Cine MR imaging with simultaneously acquired audio files was performed in 3 adult volunteers to optimize the protocol and then in 5 pediatric volunteers meeting the inclusion criteria. MAIN OUTCOME MEASURES: High-resolution cine MR images with clear intelligible audio recordings of specific phonatory tasks. RESULTS: Using 3 healthy adult volunteers, a cine MR imaging VPI protocol was developed that links simultaneously acquired cine MR images to audio recordings of specific validated phonatory tasks. Five school-aged children with VPI from our multidisciplinary pediatric airway center were then enrolled and underwent cine MR imaging using this protocol. The cine MR images and audio recordings acquired were of sufficient diagnostic quality to evaluate VPI closure patterns in school-aged children with VPI. CONCLUSION: Cine MR imaging linked to audio is a quick, safe, and well-tolerated dynamic diagnostic imaging tool that may eventually have the potential to guide more precisely the selection and application of surgical techniques for VPI.

Injection pharyngoplasty with calcium hydroxylapatite for velopharyngeal insufficiency: patient selection and technique.

OBJECTIVE: To identify children who may benefit from calcium hydroxylapatite (CaHA) injection pharyngoplasty for symptomatic velopharyngeal insufficiency (VPI). DESIGN: Retrospective review of children with VPI who underwent injection pharyngoplasty with CaHA. SETTING: Multidisciplinary pediatric aerodigestive center. PATIENTS: Children with symptomatic VPI as defined by abnormal speech associated with subjective and objective measures of hypernasality. INTERVENTION: Posterior pharyngeal wall augmentation with injectable CaHA. MAIN OUTCOME MEASURE: Nasalence scores recorded as number of standard deviations (SDs) from normalized scores, and perceptual scoring recorded as standardized weighted score and caretaker satisfaction from direct report. RESULTS: Twelve children who had undergone injection pharyngoplasty with CaHA were identified. Of the 12 children, 8 demonstrated success at 3 months as defined by nasalence (<1 SD above normal nasalance scores), perceptual scoring (decrease in weighted score), and overall caretaker satisfaction. Four children were followed up for more than 24 months and continued to demonstrate stable success. The 4 children who failed the procedure all failed before the 3-month evaluation and demonstrated increased baseline severity of VPI as defined by increased preoperative nasalence scores (5.25 SD vs 2.4 SD above normalized scores), perceptual scores (weighted score, 4.25 vs 3.85), and characteristic nasendoscopy findings of a broad-based velopharyngeal gap or unilateral adynamism. Three of the 4 treatment failures occurred early in the senior author's (C.J.H.) experience with the technique. CONCLUSIONS: Injection pharyngoplasty with CaHA is a useful adjunct in the treatment of children with mild VPI. Efficacy and safety have been demonstrated more than 24 months after injection. Patient selection and operative technique are critical to the success of the procedure. Success is seen most often in children with mild VPI and small well-defined velopharyngeal gaps consistent with touch closure.