Airway Impedance: A Novel Diagnostic Tool to Predict Extraesophageal Airway Inflammation.

OBJECTIVE: To validate a novel biomarker, airway impedance for extraesophageal disease. STUDY DESIGN: We prospectively recruited patients with respiratory symptoms undergoing combined endoscopy and direct laryngoscopy for the evaluation of symptoms. The direct laryngoscopy was performed and videotaped for blinded scoring by 3 otolaryngologists and an impedance catheter was placed onto the posterior larynx to obtain measurements. Following this, an endoscopy was performed and impedance measurements and biopsies were taken at 3 esophageal heights. Impedance values were compared within and between patients. RESULTS: Eighty-eight patients were recruited, of which 73 had complete airway and endoscopic exams. There was no significant correlation between airway impedance values and mean reflux finding scores (r2 = 0.45, P = .07). There was no significant positive correlation between airway impedance and esophageal impedance values (r2 = 0.097-0.138, P > .2). Patients taking proton pump inhibitors had significantly lower mean airway impedance values (706 ± 450 Ω) than patients not taking them (1069 ± 809 Ω, P = .06). Patients who had evidence of aspiration on video fluoroscopic swallow studies had lower airway impedance (871 ± 615 Ω) than patients without aspiration (1247 ± 360 Ω, P = .008). Inhaled steroids did not impact airway impedance levels (P = .7). CONCLUSIONS: Airway impedance may be an important diagnostic tool to diagnose gastroesophageal reflux or aspiration, eliminating the subjectivity of airway appearance alone.

Upper Airway Anomalies in Congenital Tracheoesophageal Fistula and Esophageal Atresia Patients.

OBJECTIVE: To examine the prevalence of upper airway anomalies in patients diagnosed with congenital tracheoesophageal fistula and esophageal atresia (TEF/EA). METHODS: A retrospective review was conducted of all TEF/EA patients seen at a tertiary pediatric hospital between January 2008 and December 2013. Inclusion criteria included evaluation by the otolaryngology service. Exclusion criteria included age>18 years, acquired TEF/EA, subsequent rule out of TEF/EA, and otolaryngology evaluation for reasons not pertaining to the airway. Data collected and analyzed included demographics, comorbidities, presenting symptoms, surgical interventions, laryngoscopic and bronchoscopic examinations, and subsequent medical and surgical management. RESULTS: Four hundred and thirty patients were diagnosed with TEF/EA at our institution. In all, 32.3%, or 139 children, were included in the analysis; 56.1% (n=78) male, 43.9% (n=61) female. Of the analyzed patients, 4.3% (n=6) were diagnosed with laryngomalacia. Eighteen patients (12.9%) were diagnosed with subglottic stenosis. Thirty (21.6%) had vocal fold paresis or immobility. Laryngeal cleft was diagnosed in 25.9% (n=36). Tracheomalacia was the most common airway finding, diagnosed in 37.4% (n=52) patients. CONCLUSION: Patients diagnosed with congenital TEF/EA have a high rate of secondary upper airway anomalies. Consideration should be given to perform a complete airway evaluation in all of these patients.

Voice as a Biomarker of Pediatric Health: A Scoping Review.

The human voice has the potential to serve as a valuable biomarker for the early detection, diagnosis, and monitoring of pediatric conditions. This scoping review synthesizes the current knowledge on the application of artificial intelligence (AI) in analyzing pediatric voice as a biomarker for health. The included studies featured voice recordings from pediatric populations aged 0-17 years, utilized feature extraction methods, and analyzed pathological biomarkers using AI models. Data from 62 studies were extracted, encompassing study and participant characteristics, recording sources, feature extraction methods, and AI models. Data from 39 models across 35 studies were evaluated for accuracy, sensitivity, and specificity. The review showed a global representation of pediatric voice studies, with a focus on developmental, respiratory, speech, and language conditions. The most frequently studied conditions were autism spectrum disorder, intellectual disabilities, asphyxia, and asthma. Mel-Frequency Cepstral Coefficients were the most utilized feature extraction method, while Support Vector Machines were the predominant AI model. The analysis of pediatric voice using AI demonstrates promise as a non-invasive, cost-effective biomarker for a broad spectrum of pediatric conditions. Further research is necessary to standardize the feature extraction methods and AI models utilized for the evaluation of pediatric voice as a biomarker for health. Standardization has significant potential to enhance the accuracy and applicability of these tools in clinical settings across a variety of conditions and voice recording types. Further development of this field has enormous potential for the creation of innovative diagnostic tools and interventions for pediatric populations globally.

Diagnostic Accuracy of Laryngeal Ultrasound for Evaluating Vocal Fold Movement Impairment in Children.

PURPOSE: Vocal fold movement impairment (VFMI) secondary to recurrent laryngeal nerve (RLN) injury is a common source of morbidity after pediatric cervical, thoracic, and cardiac procedures. Flexible laryngoscopy (FL) is the gold standard to diagnose VFMI yet can be challenging to perform and/or risks possible clinical decompensation in some children and is an aerosolizing procedure. Laryngeal ultrasound (LUS) is a potential non-invasive alternative, but limited data exists in the pediatric surgical population regarding its efficacy. We aimed to investigate the diagnostic accuracy of LUS compared to FL in evaluating VFMI. METHODS: A prospective, single-center, single-blinded (rater) cohort study was undertaken on perioperative pediatric patients at risk for RLN injury. Patients underwent FL and LUS. Cohen's kappa was used to determine chance-corrected agreement. RESULTS: Between 2021 and 2023, 85 paired evaluations were performed with patients having a median (IQR) age of 10 (4, 42) months and weight of 7.5 (5.4, 13.4) kilograms. The prevalence of VFMI was 27.1%. Absolute agreement between evaluations was 98.8% (kappa 0.97, 95% CI: 0.91-1.00, P < 0.001). The sensitivity and specificity of LUS in detecting VFMI was 95.7% and 100%, yielding a positive predictive value (PPV) of 100% and negative predictive value (NPV) of 98.4% (95% CI: 90-100%). Diagnostic accuracy was 98.8% (95% CI: 93-100%). CONCLUSION: LUS is a highly accurate modality in evaluating VFMI in children. While FL remains the gold standard for diagnosis, LUS offers a low-risk screening modality for children at risk for VFMI such that only those with an abnormal LUS or presence of clinical symptoms discordant with LUS findings should undergo FL. TYPE OF STUDY: Prospective, single-center, single blinded (rater), cohort study. LEVEL OF EVIDENCE: Level II.

Barriers to Voice Therapy in Dysphonic Children.

BACKGROUND: The most common etiologies of dysphonia in the pediatric population are vocal fold nodules and muscle tension dysphonia. Vocal therapy is the first line treatment for these disorders in children. Despite this, not all children undergo therapy. The goal of this study is to examine how factors such as patient demographics and parental perceptions differ between children that choose to undergo or not to undergo voice therapy. METHODS: A retrospective review was conducted of all pediatric patients seen at a tertiary voice clinic between January 2014 and December 2017. Patients were included if diagnosed with vocal fold nodules and/or muscle tension dysphonia. Patients were divided into groups of children that received voice therapy at our institution and those that did not. Data include demographics, Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) scores and pediatric Voice Handicap Index (pVHI) scores. Distance to therapy site was approximated using patient zip codes. RESULTS: Three hundred and forty-six children were included, 224 (65%) boys and 122 (35%) girls. In the 2 years following initial diagnosis, 74 (21%) children participated in voice therapy at our institution. Patients who underwent voice therapy were older than those who did not (mean age: 9.1 [SD 3.5] vs 7.6 [SD 3.8] years; P = 0.004). Patients who received voice therapy were more likely to live closer to the therapy site (mean distance: 15.5 [SD 13.0] vs 24.3 [SD 23.9] miles; P< 0.001). Likelihood of receiving voice therapy did not differ by gender or health insurance status (private vs public). Patients who underwent voice therapy had significantly greater CAPE-V Overall Severity scores than those who did not (mean score: 44.6 [SD 19.4] vs 37.4 [SD 18.0]; P = 0.003). Higher CAPE-V Strain scores were associated with increased likelihood of voice therapy. pVHI scores did not differ between the two groups. CONCLUSION: Older age, shorter distance to therapy site, and increased CAPE-V Overall Severity and Strain scores were associated with higher likelihood of receiving voice therapy. Gender, insurance status, and pVHI scores did not affect likelihood of receiving voice therapy. Patients may primarily consider ease of access and necessity of treatment when considering voice therapy.

Pediatric Dysphonia: When to Refer.

The reported prevalence of voice disorders in the pediatric population varies widely between studies, ranging from 3.9% to 23%. Despite this, not all children with dysphonia are referred to a voice specialist for further evaluation. The objective of this study is to examine the relationship between dysphonia history, voice assessment, and laryngeal findings to help guide referrals of dysphonic children. A retrospective review was conducted of pediatric patients at a tertiary voice clinic between January 2014 and December 2017. Data including dates of presentation, demographics, co-morbidities, presenting symptoms, laryngeal exam findings, Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) scores, and Pediatric Voice Handicap Index (pVHI) scores were collected and analyzed. Of 475 patients initially identified, 459 met inclusion criteria and were reviewed. In all, 272 (59.3%) were male and 187 (40.7%) were female. Mean age at first presentation was 8.6 years old (range: 2-18). Males were more likely to present at a younger age than females. CAPE-V data were available for 439 patients, and pVHI data were available for 109 patients. The mean CAPE-V Overall Severity score was 38.2. The mean total pVHI score was 25.4. Males had higher CAPE-V Overall Severity (40.0 vs. 35.4), Roughness (32.2 vs. 27.6), and Strain scores (37.2 vs. 32.4) than females. Patient pVHI scores did not differ by gender. In all, 283 patients self-reported a length of symptoms prior to evaluation. Children with a longer duration of symptoms prior to evaluation had higher CAPE-V Overall Severity scores. Diagnoses of vocal fold movement impairment and benign vocal fold lesions that were not nodules were associated with higher average CAPE-V Overall Severity scores. Overall, 310 patients (67.5%) were recommended intervention for their dysphonia. These patients had higher CAPE-V Overall Severity scores than those who were solely recommended observation (42.8 vs. 28.0). Males were more likely than females to present with dysphonia and presented with more severe perceptual dysphonia scores on average. The length of symptoms and certain diagnoses correlated with higher CAPE-V Scores. Referrals to a pediatric voice clinic should be considered in patients with a dysphonia history lasting greater than 3 months and in patients with more severe symptoms.

Comparative Study of Pharyngeal Flap Outcomes between Children With 22q11.2 Deletion Syndrome and Non-Syndromic Cleft Lip and Palate.

BACKGROUND: Management of velopharyngeal insufficiency (VPI) in 22q11.2 deletion syndrome (22q) is challenging. This study compares pharyngeal flap outcomes in children with 22q to those with non-syndromic cleft lip and palate (CLP) to assess risk of poor speech outcomes and negative sequelae. METHODS: Children with 22q or CLP treated with pharyngeal flap through a multidisciplinary VPI clinic between 2009 and 2020 were retrospectively reviewed. Pre- and postoperative speech assessments, perioperative characteristics, and complications were identified. RESULTS: 36 children with ​22q and 40 with CLP were included. Age at surgery (p=0.121), pre-operative velopharyngeal competence score (VPC) (p=0.702), and pre-operative resonance (p=0.999) were similar between groups. Pharyngeal flaps were wider (p=0.038*) and length of stay longer in the 22q group (p=0.031*). On short term follow 4 months after surgery, similar speech outcomes were seen between groups. At long term follow up >12 months after surgery, 86.7% 22q v. 100% CLP (p=0.122) had improvement in velopharyngeal function, however fewer children with 22q (60.0%) achieved a completely "competent" VPC score compared to those with CLP (92.6%) (p=0.016*). Nasal regurgitation improved for both groups, with a greater improvement in those with 22q (p=0.026*). Revision rate (p=0.609) and new onset OSA (0.999) were similar between groups. CONCLUSION: Children with 22q have improved speech after pharyngeal flap, but may be less likely to reach normal velopharyngeal function over the long term than those with CLP; however, negative sequelae do not differ. Improvement in nasal regurgitation is a uniquely positive outcome in this population.

Laryngeal pathologies in dysphonic children with Down Syndrome.

INTRODUCTION: Down syndrome is the most common chromosomal abnormality and is associated with a higher incidence of congenital heart defects, which often require surgery within the first year of life. Previous studies have found that children with Down syndrome are at higher risk for subglottic stenosis, vocal fold paralysis, and laryngomalacia. The goal of this study is to review children with Down syndrome presenting with dysphonia and to characterize their laryngeal pathologies. METHODS: A retrospective review was performed of patients with Down syndrome seen at a tertiary pediatric hospital's department of otolaryngology from Jan. 2007-Jul. 2021 for voice-related concerns. Inclusion criteria included age less than 18 years, diagnosis of Trisomy 21, and complaint of dysphonia. The data extracted included history of dysphonia, co-morbidities, demographic information, age at presentation, perceptual voice assessments, voice quality of life scores, acoustic data, laryngoscopic and/or videostroboscopic exams, and surgical procedures. RESULTS: Twenty-three total patients met the study criteria. Of these children, 13 (57%) were male and 10 (43%) were female. The mean age at first presentation was 4.08 years (range 12 days-16.3 years). Eleven of the 23 patients presented within the first 12 months of life. Sixteen patients were diagnosed with vocal fold immobility, 13 of which were left-sided unilateral immobility and the remaining 3 were bilateral immobility. 5 patients were diagnosed with vocal fold nodules. 12 children in the immobility group had a history of cardiothoracic surgery at our institution. Only 3 patients had Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) assessments, though all three showed overall dysphonia ratings of severely deviant, with roughness and strain scores being the most severe. DISCUSSION: The most common etiology of dysphonia in our Down syndrome patient population was vocal fold immobility and hypomobility, as opposed to vocal fold nodules (which is the most common in the general pediatric population). The higher likelihood of cardiac surgery in patients with Trisomy 21 may result in the increased incidence of vocal fold immobility. There should be a low threshold to refer dysphonic patients with Down syndrome for laryngoscopic evaluation, as treatment options may be available.

Telehealth for Treatment of Pediatric Dysphonia.

BACKGROUND: Vocal fold nodules are the most common etiology of chronic dysphonia in the pediatric population. Voice therapy is an effective first line of treatment, with increasing evidence supporting the use of telepractice in speech pathology. Despite this, there is limited data on its effectiveness in the pediatric population. The aim of this retrospective study was to investigate the feasibility and efficacy of telepractice in delivering voice therapy to children diagnosed with vocal fold nodules. METHODS: A retrospective review was conducted of patients treated with virtual voice therapy from April 2020 to June 2021. Patients were included if diagnosed with vocal fold nodules, 2-18 years of age, and completed therapy in a virtual format. Data includes demographics, Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) scores and pediatric Voice Handicap Index (pVHI) scores. RESULTS: Twenty-three children were included, 17 (74%) male and six (26%) female (with an age range of 2.4-9.9 years at the start of therapy). Prior to treatment, the average CAPE-V Overall Severity score was 37.9 (SD 13.8); the average posttreatment score was 22.4 (SD 10.2). The average pVHI total score prior to treatment was 26.3 (SD 12.1), with an average posttreatment score of 20.2 (SD 11.7). Patients who underwent virtual voice therapy had improved posttreatment CAPE-V severity scores than those prior to treatment (average difference = -15.5 points; 95% CI: -8.3 to -22.7; P < 0.001). An increased number of therapy sessions was associated with both higher initial CAPE-V severity scores (r = 0.72; P < 0.01) and a greater decrease in posttreatment CAPE-V scores (r = -0.55; P < 0.01). CONCLUSION: Virtual voice therapy may be feasible and efficacious in treating dysphonic children diagnosed with vocal fold nodules. Significant improvements were found in perceptual CAPE-V scores in overall severity; positive changes were also seen in parental measures of quality of life. Delivery of voice therapy in a telehealth format may increase access of care and should be considered as a treatment option.

Tracheo-innominate fistula in children: A systematic review of literature.

OBJECTIVE: Tracheo-innominate fistula (TIF) is a rare but fatal complication of tracheotomy. To date, there is a paucity of literature regarding pediatric TIFs. The objectives of this study were to conduct a systematic review of literature on pediatric TIF following tracheotomy and describe three demonstrative cases from our institutional experience. METHODS: We conducted a systematic review using MEDLINE, Embase, Cochrane Database of Systematic Reviews, Web of Science, and CINAHL. All studies with pediatric patients (under 18 years of age) who developed TIF following tracheotomy were included. RESULTS: Fifty-four publications met inclusion criteria, reporting on 77 cases. The most common indication for tracheotomy was prolonged intubation and the need for ventilatory support (38.6%), with neurological comorbidities being the most common indication (72.7%). The mean time to TIF was 395.7 days (95% confidence interval, 225.9-565.5). Fifty-four patients (70.1%) presented with massive hemorrhage, whereas 18 patients (23.3%) presented with a sentinel bleeding event. The most common diagnostic interventions were computed tomography scan with or without contrast and bronchoscopy (55.8%). A substantial number of patients did not have any investigations (41.6%). Surgical management occurred in 70.1% of patients. Mortality was 38.6% in reported cases with variable follow-up periods. CONCLUSION: TIF may occur in long-term tracheostomy-dependent children, contrary to the conventionally described 3-week postoperative period. The mortality may not be as high as previously reported with timely intervention. Our results are limited by inherent risks of bias. Further research including well-designed cohort studies are needed to guide an evidence-based approach to TIF. LEVEL OF EVIDENCE: NA Laryngoscope, 130:217-224, 2020.

Beyond Nodules-Diagnostic and Treatment Options in Pediatric Voice Disorders.

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.

Medialization Laryngoplasty in Pediatric Patients With Unilateral Vocal Fold Immobility: A Case Series.

OBJECTIVES:: The aims of this study were to describe the impact of laryngoplasty in pediatric unilateral vocal fold immobility (UVFI) and to determine the impact of etiology and technique on voice and swallowing. METHODS:: A retrospective review was conducted of all children with UVFI undergoing medialization laryngoplasty at a pediatric hospital (2010-2017). Data including demographics, etiology, subjective voice quality, and swallowing function were collected. RESULTS:: The median age at first surgery among 25 patients with UVFI was 11 years (range, 1.2-25 years). The causes of UVFI were iatrogenic (76%), congenital (16%), and idiopathic (8%). A total of 38 laryngoplasties (24 injections, 11 Silastic implants, 3 Gore-Tex) were performed. Postoperatively, 78% of patients reported improvements in voice and 81% in swallowing. The median duration of voice improvement was 1.0 years (range, 0.1-10 years), with no significant difference by etiology or laryngoplasty technique. Patients who were ⩾10 years of age at surgery reported voice improvement significantly more often than patients <10 years of age at surgery (94% vs 61%, P = .04). CONCLUSIONS:: UVFI has a significant impact on health and quality of life. In this study we found that laryngoplasty is an effective way to address both voice and swallowing in pediatric UVFI. A greater proportion of children with improved voice quality were older at injection. Surprisingly, there was no difference in duration of voice improvement between permanent and absorbable materials. Although this duration would be considered acceptable for many injectable materials, the limited duration in permanent implantation techniques may represent the challenges of managing UVFI in the growing larynx of the pediatric population. Injection laryngoplasty with absorbable materials may serve as an adequate method of addressing UVFI in this population.

Vocal Pitch Discrimination in Children with and without Vocal Fold Nodules.

Vocal pitch discrimination abilities were compared in sixteen children with vocal fold nodules (CwVN) and sixteen matched controls with typical voices (CwTV). Vocal pitch discrimination was also evaluated in thirty-five vocally healthy children and twenty adults to examine potential changes as a function of maturation. CwTV were categorized as either younger (N = 15, 5.6-7.7 years) or older (N = 20, 8.2-11.7 years). Participants completed two-alternative, forced choice listening tasks in which they judged whether pairs of sustained /α/ tokens were different in pitch. Each pair consisted of a base token with a fundamental frequency fo ) of 216.2 Hz and a test token with a fo that was adaptively modified, according to the participant's prior judgments. There were no significant differences in pitch discrimination abilities between CwVN and CwTV. Pitch discrimination abilities were significantly poorer in younger and older CwTV as compared to adults. Additionally, younger CwTV had significantly poorer discrimination abilities than older CwTV. Findings from this study suggest that CwVN do not have differences in pitch discrimination abilities, yet, therapies designed for CwVN should consider this developmental trend in perceptual abilities.

Prevalence of voice disturbances in pediatric airway patients: Are we missing anything?

OBJECTIVE: To report on the prevalence of voice disturbances in pediatric airway patients. METHODS: Consecutive patients seen in a specialized Center for Airway Disorders at a tertiary children's hospital from February 2017 to September 2017 were included. Patients' families were invited to complete a pediatric voice health handicap index (pVHI) questionnaire. Patients underwent evaluation including flexible laryngoscopy and/or direct laryngoscopy and bronchoscopy. RESULTS: 146 patients were included. Of these children, 73 patients (50.3%) presented with swallowing difficulty and 44 patients (30.3%) presented with respiratory complaints. Only 9 patients (6.2%) reported hoarseness initially. The median age at referral was 2.7 years of age (interquartile range: 1.4-4.3). The mean total pVHI score was 9.5 (± 12.9). Sixty-seven patients (45.9%) had abnormal pVHI findings of score > 4. Six patients (4.1%) had pVHI > 40. The mean pVHI score was 26.0 (± 21.1) among 12 patients with a history of tracheostomy, 12.0 (± 14.3) among 30 patients with laryngeal cleft, and 9.0 (± 9.9) among 19 patients with laryngomalacia. CONCLUSION: Voice disturbances are not uncommon in pediatric patients evaluated for airway disorders. Although patients may present with primary concerns for breathing or swallowing difficulties, many of these patients may need further work-up and treatment for dysphonia.

Aspiration in children with unilateral vocal fold paralysis.

OBJECTIVES/HYPOTHESIS: To describe the prevalence of aspiration in children with unilateral vocal fold paralysis who underwent objective assessment of swallow function. STUDY DESIGN: Retrospective chart review. METHODS: A study of patients presenting to our institution with unilateral vocal fold paralysis in 2015 was conducted. All patients were diagnosed using flexible laryngoscopy. Patients were included if they underwent at least one modified barium swallow (MBS) study for evaluation of their swallowing function due to recurrent respiratory issues and/or feeding difficulty. RESULTS: Twenty-eight patients diagnosed with unilateral vocal fold paralysis underwent an MBS study at our institution in 2015. Median age at the time of MBS study was 1.7 years (interquartile range: 0.4-4.3). Twenty-six patients (92.9%) had dysphagia. Sixteen patients were found to aspirate on MBS study. All patients who aspirated did so without overt signs (silent aspiration). Eighteen patients had congenital heart disease (64.3%) and nine had a history of prematurity (32.1%). Eight patients (28.6%) presented with developmental delays. CONCLUSIONS: Patients who present with unilateral vocal fold paralysis and recurrent respiratory and/or feeding issues may be affected by prominent issues such as swallowing dysfunction and silent aspiration. Clinicians should be aware of this risk and evaluate patients for any signs of feeding or swallowing difficulties. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:569-573, 2019.

Voice Abnormalities and Laryngeal Pathology in Preterm Children.

INTRODUCTION: The prevalence of voice abnormalities in children born prematurely has been reported to be as high as 58%. Few studies have examined these abnormalities with laryngoscopic or videostroboscopic findings and characterized their laryngeal pathologies. OBJECTIVE: To review voice abnormalities in patients with a history of prematurity and characterize the etiology of their voice problems. A secondary objective is to see if there is a correlation between the findings and the patient's intubation and surgical history. METHODS: A retrospective chart review was conducted of all preterm patients seen in voice clinic at a tertiary pediatric hospital. Demographic data, diagnoses, and office laryngoscopies were reviewed as well as any speech therapy evaluations and/or medical and surgical treatments. RESULTS: Fifty-seven patients were included. Mean age at presentation was 5.1 (±4.3) years. Mean gestational age was 27.8 (±3.7) weeks. Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) perceptual evaluations included a mean overall dysphonia severity of 46.6 (±24.2). Patients who had undergone prolonged intubation (⩾28 days) in the NICU or had prolonged NICU stays (>12 weeks) had significantly higher overall dysphonia severity scores. Thirty-three patients with vocal fold hypo- or immobility had significantly greater voice deviance in breathiness, loudness, and overall severity compared to those without vocal fold immobility. Of all patients, 35% were recommended surgical intervention and 49% voice therapy. CONCLUSION: Intubation greater than 28 days and prolonged NICU stays are associated with more severe dysphonia in premature patients. There should be a low threshold for clinical evaluation of dysphonia in this unique patient population.

Congenital Atresia of Wharton's Duct.

This is a case report of a three-month-old male who presented to clinic with a cystic lesion under the tongue. On clinical examination, a cystic lesion was observed in the, floor-of-mouth. The patient was referred to Paediatric Otorhinolaryngology service for further management. The differential diagnoses for floor-of-mouth lesions should be reviewed with primary focus on the Wharton's duct atresia and its management. It is crucial to recognize submandibular duct atresia in the primary Paediatric clinic in order to expedite management of lesion before complications arise including infection, enlargement of cyst, and feeding and breathing difficulties.

Paradoxical vocal fold motion in children presenting with exercise induced dyspnea.

INTRODUCTION: Although dyspnea with exercise in the pediatric population can be multifactorial, the diagnosis of paradoxical vocal fold motion disorder (PVFMD) in this group is not well characterized. The objective of this study is to review the multiple causes of dyspnea with exercise in children, including the prevalence of PVFMD within this study population. METHODS: A retrospective review was conducted of patients seen at a tertiary pediatric hospital for exercise-induced dyspnea suspected to be related to PVFMD between January 2007 and July 2015. Inclusion criteria included assessment in a specialty exercise clinic and evaluation by a pediatric otolaryngologist and pulmonologist. Pre- and post-exercise pulmonary function tests and laryngoscopic examinations were performed. Data including co-morbidities, presenting symptoms, prior diagnoses and treatments, final diagnoses, prescribed treatments and outcomes were collected and analyzed. RESULTS: 294 patients were evaluated at our institution during the study period. 4 patients were excluded for insufficient data, which left 290 for analysis. 75 were male, 215 female. All patients underwent treadmill testing with monitoring to simulate strenuous exercise. Average patient age was 14.6 years; average BMI was 21.53. The most common sports to elicit symptoms were running and soccer. Patients most frequently complained of stridor or wheezing in addition to dyspnea. Throat tightness was also a common complaint. After evaluation, 86 patients were given the primary diagnosis of exercise-induced PVFMD. 54 patients were diagnosed with physiologic dyspnea and 30 with exercise-induced asthma. CONCLUSION: Pediatric patients presenting with exercise-induced dyspnea can have multiple etiologies for their symptoms including PVFMD. Other causes of dyspnea with exercise should not be underestimated.

Pediatric nodular fasciitis in the head and neck: evaluation and management.

IMPORTANCE: Nodular fasciitis is a rare benign tumor that can present in the head and neck in children. A better understanding of this rare condition is critical to optimize management. OBJECTIVE: To review the presentation, evaluation, diagnosis, and management of pediatric nodular fasciitis of the head and neck. DESIGN, SETTING, AND PARTICIPANTS: Retrospective review of all patients treated for nodular fasciitis of the head and neck over a 20-year period at a pediatric tertiary care center. INTERVENTION: Surgical excision. MAIN OUTCOMES AND MEASURES: Clinical data, including age, presenting symptoms, anatomical site(s), evaluation, treatment, and complications. RESULTS: Fifteen children with pathologically confirmed nodular fasciitis of the head and neck were identified, including 8 boys and 7 girls. The median (range) age at diagnosis was 9.3 years (2 months to 18 years). Patients most commonly presented with a firm, enlarging soft-tissue mass. Two patients reported pain, and 1 patient presented with erythema. The most common location was the maxillofacial region (5 patients). Other locations included the scalp (3 patients), forehead (2 patients), neck (2 patients), mandible (1 patient), postauricular region (1 patient), and nasal dorsum (1 patient). One patient reported a preceding trauma, and 1 patient, a preceding infection. Presurgical imaging varied; imaging modalities used included computed tomography, magnetic resonance imaging, radiography, ultrasound, and sialography. All patients underwent surgical excision, which focused on excising the mass while preserving surrounding normal tissues. Mean (range) follow-up was 7.69 (0-46) months. Two minor complications were reported: 1 patient who underwent a near-total excisional biopsy experienced residual firmness and tenderness at the site of the lesion and another patient was left with an unfavorable cosmetic scar that necessitated intralesional steroid injection. No patient demonstrated recurrence at follow-up. CONCLUSIONS AND RELEVANCE: Although an uncommon diagnosis, nodular fasciitis should be considered in the evaluation and treatment of head and neck soft-tissue masses in children. Preoperative imaging is nonspecific and variable. Pathological findings are necessary for diagnosis. Surgical excisional biopsy is curative, with no instances of recurrence in our series.