Exercise induced laryngeal obstruction (EILO) in children and young people: Approaches to assessment and management.

Exercise Induced Laryngeal Obstruction (EILO) is characterised by breathlessness, cough and/or noisy breathing particularly during high intensity exercise. EILO is a subcategory of inducible laryngeal obstruction where exercise is the trigger that provokes inappropriate transient glottic or supraglottic narrowing. It is a common condition affecting 5.7-7.5% of the general population and is a key differential diagnosis for young athletes presenting with exercise related dyspnoea where prevalence rates go as high as 34%. Although the condition has been recognised for a long time, little attention, and awareness of the condition results in many young people dropping out of sporting participation due to troublesome symptoms. With evolving understanding of the condition, diagnostic tests and interventions, this review looks to present the current available evidence and best practice when managing young people with EILO.

Complete Laryngo-Tracheo-Oesophageal Cleft masquerading as Oesophageal Atresia and Tracheo-oesophageal Fistula: A Potential Diagnostic and Management Challenge.

Newborn babies presenting with difficulties related to the aerodigestive tract (ADT) are often provisionally diagnosed and managed as having oesophageal atresia +/- tracheo-oesophageal fistula. Continuing difficulties with management and abnormal findings on investigations should lead to the consideration of other congenital anomalies of the ADT, including complete larnygo-tracheo-oesophageal cleft (LTOC). We present two patients who were eventually diagnosed with complete LTOC and care was withdrawn. We discuss the inherent difficulties in reaching this diagnosis and present an algorithm to help manage these rare and challenging situations.

International pediatric otolaryngology group (IPOG) consensus on approach to aspiration.

OBJECTIVE: To provide recommendations for a comprehensive management approach for infants and children presenting with symptoms or signs of aspiration. METHODS: Three rounds of surveys were sent to authors from 23 institutions worldwide. The threshold for the critical level of agreement among respondents was set at 80 %. To develop the definition of "intractable aspiration," each author was first asked to define the condition. Second, each author was asked to complete a 5-point Likert scale to specify the level of agreement with the definition derived in the first step. RESULTS: Recommendations by the authors regarding the clinical presentation, diagnostic considerations, and medical and surgical management options for aspiration in children. CONCLUSION: Approach to pediatric aspiration is best achieved by implementing a multidisciplinary approach with a comprehensive investigation strategy and different treatment options.

Comprehensive management of anterior drooling: An International Pediatric Otolaryngology Group (IPOG) consensus statement.

OBJECTIVE: To provide guidance for the comprehensive management of children referred for anterior drooling. The mission of the International Pediatric Otolaryngology Group (IPOG) is to develop expertise-based recommendations for the management of pediatric otolaryngologic disorders with the goal of improving patient care. METHODS: Survey of expert opinion by the members of the International Pediatric Otolaryngology Group (IPOG). The recommendations are derived from current expert consensus and critical review of the literature. RESULTS: Consensus recommendations include initial care and approach recommendations for health care providers who commonly evaluate children with drooling. This includes evaluation and treatment considerations for commonly debated issues in drooling management, initial work-up of children referred for anterior drooling, treatment recommendations, indications and contra-indications for rehabilitation, medical, and surgical management, as well as pros and cons of different surgical procedures in the hands of drooling management experts. CONCLUSION: Anterior drooling consensus recommendations are aimed at improving patient-centered care in children referred for sialorrhea.

International Pediatric Otolaryngology Group (IPOG) consensus on scoring of pediatric Drug Induced Sleep Endoscopy (DISE).

OBJECTIVES: To develop consensus statements for the scoring of pediatric drug induced sleep endoscopy in the diagnosis and management of pediatric obstructive sleep apnea. METHODS: The leadership group identified experts based on defined criteria and invited 18 panelists to participate in the consensus statement development group. A modified Delphi process was used to formally quantify consensus from opinion. A modified Delphi priori process was established, which included a literature review, submission of statements by panelists, and an iterative process of voting to determine consensus. Voting was based on a 9-point Likert scale. Statements achieving a mean score greater than 7 with one or fewer outliers were defined as reaching consensus. Statements achieving a mean score greater than 6.5 with two or fewer outliers were defined as near consensus. Statements with lower scores or more outliers were defined as no consensus. RESULTS: A total of 78 consensus statements were evaluated by the panelists at the first survey - 49 achieved consensus, 18 achieved near consensus, and 11 did not achieve consensus. In the second survey, 16 statements reached consensus and 5 reached near consensus. Regarding scoring, consensus was achieved on the utilization of a 3-point Likert scale for each anatomic site for maximal observed obstructions of <50% (Score 0, no-obstruction), ≥ 50% but <90% (Score 2, partial obstruction), and ≥ 90% (Score 3, complete obstruction). Anatomic sites to be scored during DISE that reached consensus or near-consensus were the nasal passages, adenoid pad, velum, lateral pharyngeal walls, tonsils (if present), tongue base, epiglottis, and arytenoids. CONCLUSION: This study developed consensus statements on the scoring of DISE in pediatric otolaryngology using a modified Delphi process. The use of a priori process, literature review, and iterative voting method allowed for the formal quantification of consensus from expert opinion. The results of this study may provide guidance for standardizing scoring of DISE in pediatric patients.

Pediatric Dysfunctional Breathing: Proposed Components, Mechanisms, Diagnosis, and Management.

Dysfunctional breathing (DB) is an overarching term describing deviations in the normal biomechanical patterns of breathing which have a significant impact on quality of life, performance and functioning. Whilst it occurs in both children and adults, this article focuses specifically on children. DB can be viewed as having two components; breathing pattern disorder (BPD) and inducible laryngeal obstruction (ILO). They can be considered in isolation, however, are intricately related and often co-exist. When both are suspected, we propose both BPD and ILO be investigated within an all-encompassing multi-disciplinary dysfunctional breathing clinic. The MDT clinic can diagnose DB through expert history taking and a choice of appropriate tests/examinations which may include spirometry, breathing pattern analysis, exercise testing and laryngoscopic examination. Use of the proposed algorithm presented in this article will aid decision making regarding choosing the most appropriate tests and understanding the diagnostic implications of these tests. The most common symptoms of DB are shortness of breath and chest discomfort, often during exercise. Patients with DB typically present with normal spirometry and an altered breathing pattern at rest which is amplified during exercise. In pediatric ILO, abnormalities of the upper airway such as cobblestoning are commonly seen followed by abnormal activity of the upper airway structures provoked by exercise. This may be associated with a varying degree of stridor. The symptoms, however, are often misdiagnosed as asthma and the picture can be further complicated by the common co-presentation of DB and asthma. Associated conditions such as asthma, extra-esophageal reflux, rhinitis, and allergy must be treated appropriately and well controlled before any directed therapy for DB can be started if therapy is to be successful. DB in pediatrics is commonly treated with a course of non-pharmaceutical therapy. The therapy is provided by an experienced physiotherapist, speech and language therapist or psychologist depending on the dominant features of the DB presentation (i.e., BPD or ILO in combination or in isolation) and some patients will benefit from input from more than one of these disciplines. An individualized treatment program based on expert assessment and personalized goals will result in a return to normal function with reoccurrence being rare.

Quality of life in paediatric tracheostomy patients and their caregivers - A cross-sectional study.

OBJECTIVES: (1) To better outline quality of life outcomes in paediatric tracheostomy patients and their caregivers. (2) To establish whether quality of life outcomes for children are associated with those of their caregivers. (3) To establish whether quality of life outcomes were associated with the demographic and clinical variables of age, duration of time with a tracheostomy, number of comorbidities, and ventilator dependence. METHODS: Cross-sectional methodology was applied to gather quantitative data on quality of life outcomes, through PedsQL written questionnaires. These questionnaires covered social, emotional, physical and role/cognitive functioning. Caregivers also provided information on communication, worries, daily activities and family relationships. All children with a tracheostomy in situ, or recently decannulated, attending Sheffield Children's Hospital during the study period were eligible for inclusion. RESULTS: 25 families wished to participate, with patients ranging from 0.5 to 16.5 years (median 6.25). Both patients and caregivers attained lower scores than many other chronic diseases studied. Mean patient HRQoL was 56.2, with a physical health score of 52.4, psychosocial health score of 61.7. Caregiver HRQoL was 63.8, family functioning score was 68.1 and total family impact score was 61.6. Relative deficits were seen in caregiver social functioning (54.9), communication (56.3), worries (49.1) and daily activities (48.9), whilst role/cognitive functioning (73.8) and family relationships (79.6) subsections produced higher scores. Child psychosocial health showed moderate positive correlation (r = 0.492, p = 0.015) with both caregiver HRQoL and total family impact score. No correlation was identified between quality of life outcomes and demographic or clinical variables. CONCLUSIONS: Disease burden appears to be particularly high for children and families with tracheostomies, especially when compared to other serious childhood disease. Lack of time and energy to complete daily activities, social isolation, worries, as well as difficulty communicating and perceived lack of understanding of their child's health were instrumental in reduced quality of life of caregivers. Anxiety about the future affected the majority of caregivers. This psychosocial impact may be lost in the busyness of delivery of medical care. We recommend provision of psychosocial support for these families as is now also recommended in other chronic childhood illness.