Paediatric voice disorder: who to refer and how to assess? A summary of recent literature.

PURPOSE OF REVIEW: The purpose of this review is to update the reader with recent advances and current opinion on the assessment and management of paediatric voice disorders. RECENT FINDINGS: Access to advanced multidisciplinary paediatric voice clinics has increased over the last decade. Often the assessment is combined between speech therapy/pathology and ENT surgery. Vocal fold nodules remain the most prevalent diagnosis at a paediatric voice clinic, but significant diseases will also present, for example laryngeal papilloma. Recently, more consideration of the psychosocial aspect of voice disorders and evaluation of auditory processing disorders have shown how these can have a negative impact. There also appears to be a lack of parental and teacher awareness of paediatric voice disorders and their significance. SUMMARY: We would recommend multiparametric assessment and analysis of all children with a voice disorder. Most paediatric voice conditions will respond to skilled voice therapy. However, the exact techniques and dosage requires further evaluation and research. Paediatric voice conditions are common and should not be dismissed, as they may represent significant disease, for example papilloma, vagal palsy or have a significant psychosocial impact on the child.

Translation and validation of the Intelligibility in Context Scale into Sinhala for adolescents in Sri Lanka with cleft lip and palate.

The Intelligibility in Context Scale (ICS) is a parent-report screening tool used to measure parents' perceptions of children's functional intelligibility. This tool has been translated into over 60 languages and found to have a good reliability and validity. The purpose of the current study was to translate the ICS into Sinhala (the ICS-SIN), the main language spoken by the Sinhalese people in Sri Lanka, and to validate it with both typically developing (TD) children and children with repaired cleft lip and/or palate (CLP). The translation process followed the forward-backward-forward method. A total of 88 parents of TD children and children with CLP aged 12-15 years old (TD n = 50, CLP n = 38) completed the ICS-SIN questionnaire. Parents of TD and CLP children reported their children's speech as most intelligible to parents and least intelligible to strangers. The ICS-SIN had high internal consistency for both groups (TD α = 0.87, p < 0.05, CLP α = 0.97, p < 0.05). The ICS-SIN total scores and item scores showed significant correlations, indicating a good construct validity. TD participant group's ICS-SIN average mean scores (M = 4.88, SD = 0.29) were significantly higher compared to the CLP ICS-SIN average mean scores (M = 4.64, SD = 0.67) and varied according to gender in both groups, suggesting good discriminant validity. The ICS-SIN has overall good psychometric properties. Therefore, this tool has the potential to be used as a valid parent-rating screening tool for clinical and research purposes in Sri Lanka.

Correlating the Radiological Assessment of Patient Motion with the Incidence of Repeat Sequences Documented by Log Files.

OBJECTIVE: To correlate a radiological assessment of MR motion artifacts with the incidence of repeated sequences and delays derived from modality log files (MLFs) and investigate the suitability of log files for quantifying the operational impact of patient motion. MATERIALS AND METHODS: An experienced, blinded neuroradiologist retrospectively evaluated one full calendar month of sequentially obtained clinical MR exams of the head and/or brain for the presence of motion artifacts using a previously defined clinical grading scale. MLF data were analyzed to extract the occurrence of repeated sequences during the examinations. Statistical analysis included the determination of 95% confidence intervals for repetition ratios, and Welch's t-test to exclude the hypothesis of equal means for different groups of sequences. RESULTS: A total of 213 examinations were evaluated, comprising 1681 MLF-documented sequences, from which 1580 were archived. Radiological motion assessment scores (0, none to 4, severe) were assigned to each archived sequence. Higher motion scores correlated with a higher MLF-derived repetition probability, reflected by the average motion scores assigned to sequences that would be repeated (group 1, mean=2.5), those that are a repeat (group 2, mean=1.9), and those that are not repeated (group 3, mean=1.1) within an exam. The hypothesis of equal means was rejected with P = 5.9 × 10-5 for groups 1 and 2, P = 9.39 × 10-16 for groups 1 and 3, and P = 1.55 × 10-12 for groups 2 and 3. The repetition probability and associated time loss could be quantified for individual sequence types. The total time loss due to repeat sequence acquisition derived from MLFs was greater than four hours. CONCLUSION: Log file data may help assess patterns of scanner and exam performance and may be useful in identifying pitfalls to diagnostic imaging in a clinical environment, particularly with respect to patient motion.

Is a Close Follow-Up Computed Tomography Necessary for Acute Falcine and Tentorial Subdural Hematoma?

OBJECTIVE: This study aimed to assess the changes and values on follow-up computed tomography (F/U-CT) for isolated falcine (F-SDH) and tentorial (T-SDH) subdural hematomas (SDHs). METHOD: Fifty-four cases of isolated F-SDH and/or T-SDH were retrospectively reviewed. Subdural hematoma morphology, mass effect on the adjacent parenchyma, and interval change at F/U-CT were evaluated. Subdural hematoma size was measured parallel and perpendicular to the falx/tentorium (long or short axis, respectively). RESULTS: Short-axis increase on F/U-CT was seen only in 5 F-SDHs (16%) and 7 T-SDHs (19%), with a maximum of a 2-mm increase. Long-axis growth was more prominent and frequent, seen in 18 F-SDH patients (56.2%) and 19 T-SDH patients (51.4%), with maximum change of up to 43 mm. Falcine SDH and T-SDH were ipsilateral and contiguous in 77.8% of patients. Minimal mass effect was seen in 13 patients (24.1%), which was resolved or stable on F/U-CT. Anticoagulation did not affect SDH size. No patients required neurosurgery or died. CONCLUSIONS: Based on our limited data, the current standard of F/U-CT may be unnecessary in patients with isolated F-SDH and/or T-SDH, which expand minimally along the short axis without a significant mass effect. Characteristic anatomic structure of the tentorium and falx, and their connectivity may direct SDH expansion and limit mass effect as well as injury to the adjacent parenchyma.

Perceptual Evaluation of Voice Disorder in Children Who Have Had Laryngotracheal Reconstruction Surgery and the Relationship Between Clinician Perceptual Ratingof Voice Quality and Parent Proxy/Child Self-Report of Voice-Related Quality of Life.

Reliability of the GRBAS tool for perceptual evaluation of paediatric voice disorder is measured in this study of children with a history of laryngotracheal reconstruction surgery (LTR). Additionally, the relationship between parent proxy/child self-report of voice-related quality of life with clinician perceptual rating of voice quality is analysed. Eleven children with a history of LTR provided voice recordings following the stimuli set by the CAPE-V protocol. Subjective impact of voice quality on life was measured using the paediatric voice-related quality of life questionnaire. Four trained judges rated the sound files according to both the GRBAS and CAPE-V protocol. Intra-class correlation coefficients were high for both intra-rater and inter-rater judgments across all parameters of the GRBAS protocol, and a strong correlation was found between the grade rating of the GRBAS and the overall severity rating of the CAPE-V. Some elements of parent proxy reporting of voice-related quality of life were significantly negatively correlated with clinician perceptual rating of voice quality, while there was no significant relationship between child self-report and clinician perceptual rating.

Patterns of Stroke Transfers and Identification of Predictors for Thrombectomy.

BACKGROUND: Interhospital transfers for endovascular thrombectomy (EVT) evaluation have increased since the publication of landmark neuroendovascular stroke trials in 2015. The lack of guidelines to select potential EVT candidates prior to transfer can lead to instances where, despite considerable costs and transport risks, transferred patients do not ultimately undergo EVT. Our aim was to characterize the patterns and identify predictors for EVT on transfer. METHODS: In this observational cohort study, we retrospectively analyzed patients with acute ischemic stroke (AIS) transferred to our institution for EVT evaluation from January 2015 to March 2016. Clinical and radiographic predictors for EVT on transfer were determined with multivariable logistic regression analysis. RESULTS: A total of 103 transfer patients with AIS were included in the study, and 52% were women. A higher collateral score (P < 0.01), a higher National Institutes of Health Stroke Scale (NIHSS) score (P < 0.01), computed tomography angiography (CTA) at referring hospital (P < 0.01), and large vessel occlusion on arrival CTA (P < 0.01) were significant in patients who underwent EVT on univariable analysis. More than half (61.1%) of transfers were futile and primarily related to absence of large vessel occlusion on arrival. A higher collateral score (P = 0.02), a higher NIHSS score (P = 0.006), and having undergone a CTA at the referring center (P = 0.002) remained the independent predictors of EVT. The C statistic for the model was 0.94. CONCLUSIONS: A higher collateral score, the acquisition of CTA imaging at the referring centers, and a higher NIHSS score independently predicted EVT on transfer.

Diffusion Tensor Imaging of the Spinal Cord: Clinical Value, Investigational Applications, and Technical Limitations.

Although diffusion-weighted imaging (DWI) has become a mainstay in modern brain imaging, it remains less utilized in the evaluation of the spinal cord. Many studies have shown promise in using DWI and diffusion-tensor imaging (DTI) for evaluation of the spinal cord; however, application has been stalled by technical obstacles and artifacts, and questions remain regarding its clinical utility on an individual examination level. This review discusses the background, concepts, and technical aspects of DWI and DTI, specifically for imaging of the spinal cord. The clinical and investigational applications of spinal cord DTI, as well as the practical difficulties and limitations of DWI and DTI for the evaluation of the spinal cord are examined.

22q11 deletion syndrome: Parents' and children's experiences of educational and healthcare provision in the United Kingdom.

22q11 deletion syndrome (22q11DS) is a genetic syndrome, prevalence around 1:4000-1:6000 live births, with a complex array of associated features, impacting on healthcare and educational support. This study reports the perceptions of families and individuals with 22q11DS in relation to these needs. Individuals and families of those with 22q11DS were approached though two national charities - the Max Appeal and 22Crew. An initial observational survey design was used to gather views via questions probing access to healthcare and educational experiences. Thirty-four responses were received and the data subjected to descriptive analysis. Over half of the respondents were diagnosed before the age of 1. Ninety-one percent reported ongoing difficulties with learning at school, compounded by school attendance being compromised as a result of medical interventions. Individuals reported engaging heavily with educational support and a high number of health professions (mean 9.5; mode 10). Age of diagnosis of 22q11DS ranged from birth to nine years. Families had ongoing concerns about aspects of education and healthcare services, and lack of knowledge and awareness of the difficulties faced by individuals with 22q11DS was raised. Healthcare and education providers should be aware of the range of services individuals required on a regular basis so as to provide a more holistic approach to care.

White Paper AGA: The Impact of Mental and Psychosocial Factors on the Care of Patients With Inflammatory Bowel Disease.

Patients with chronic medically complex disorders like inflammatory bowel diseases (BD) often have mental health and psychosocial comorbid conditions. There is growing recognition that factors other than disease pathophysiology impact patients' health and wellbeing. Provision of care that encompasses medical care plus psychosocial, environmental and behavioral interventions to improve health has been termed "whole person care" and may result in achieving highest health value. There now are multiple methods to survey patients and stratify their psychosocial, mental health and environmental risk. Such survey methods are applicable to all types of IBD programs including those at academic medical centers, independent health systems and those based within independent community practice. Once a practice determines that a patient has psychosocial needs, a variety of resources are available for referral or co-management as outlined in this paper. Included in this white paper are examples of psychosocial care that is integrated into IBD practices plus innovative methods that provide remote patient management.

Association of Collateral Blood Vessels Detected by Arterial Spin Labeling Magnetic Resonance Imaging With Neurological Outcome After Ischemic Stroke.

Importance: Robust collateral blood vessels have been associated with better neurologic outcome following acute ischemic stroke (AIS). The most commonly used methods for identifying collaterals are contrast-based angiographic imaging techniques, which are not possible in all patients after AIS. Objective: To assess the association between the presence of collateral vessels identified using arterial spin labeling (ASL) magnetic resonance imaging, a technique that does not require exogenous administration of contrast, and neurologic outcome in patients after AIS. Design, Setting, and Participants: This retrospective cohort study examined 38 patients after AIS admitted to a tertiary academic medical center between 2012 and 2014 who underwent MRI with ASL. Main Outcomes and Measures: According to a prespecified hypothesis, ASL images were graded for the presence of collaterals by 2 neuroradiologists. Modified Rankin Scale (mRS) scores at discharge and other composite data were abstracted from the medical record by a neurologist blinded to radiologic data. Results: Of the 38 patients, 19 (50.0%) were male, and the mean (SD) age was 61 (20) years. In 25 of 38 patients (65.8%), collaterals were detected using ASL, which were significantly associated with both a good outcome (mRS score of 0-2 at discharge; P = .02) and a 1-point decrease in mRS score at discharge (odds ratio, 6.4; 95% CI, 1.7-23.4; P = .005). In a multivariable ordinal logistic regression model, controlling for admission National Institutes of Health Stroke Scale score, history of atrial fibrillation, premorbid mRS score, and stroke parent artery status, there was a strong association between the presence of ASL collaterals and a 1-point decrease in the mRS score at discharge (odds ratio, 5.1; 95% CI, 1.2-22.1; P = .03). Conclusions and Relevance: Following AIS, the presence of ASL collaterals is strongly associated with better neurological outcome at hospital discharge. This novel association between ASL collaterals and improved neurologic outcome may help guide prognosis and management, particularly in patients who are unable to undergo contrast-based radiological studies.

Added Value of Vessel Wall Magnetic Resonance Imaging in the Differentiation of Moyamoya Vasculopathies in a Non-Asian Cohort.

BACKGROUND AND PURPOSE: Although studies have evaluated the differential imaging of moyamoya disease and atherosclerosis, none have investigated the added value of vessel wall magnetic resonance imaging (MRI). This study evaluates the added diagnostic value of vessel wall MRI in differentiating moyamoya disease, atherosclerotic-moyamoya syndrome (A-MMS), and vasculitic-MMS (V-MMS) with a multicontrast protocol. METHODS: We retrospectively reviewed the carotid artery territories of patients with clinically defined vasculopathies (moyamoya disease, atherosclerosis, and vasculitis) and steno-occlusive intracranial carotid disease. Two neuroradiologists, blinded to clinical data reviewed the luminal imaging of each carotid, evaluating collateral extent and making a presumed diagnosis with diagnostic confidence. After 3 weeks, the 2 readers reviewed the luminal imaging+vessel wall MRI for the presence, pattern and intensity of postcontrast enhancement, T2 signal characteristics, pattern of involvement, and presumed diagnosis and confidence. RESULTS: Ten A-MMS, 3 V-MMS, and 8 moyamoya disease cases with 38 affected carotid segments were included. There was significant improvement in diagnostic accuracy with luminal imaging+vessel wall MRI when compared with luminal imaging (87% versus 32%, P<0.001). The most common vessel wall MRI findings for moyamoya disease were nonenhancing, nonremodeling lesions without T2 heterogeneity; for A-MMS eccentric, remodeling, and T2 heterogeneous lesions with mild/moderate and homogeneous/heterogeneous enhancement; and for V-MMS concentric lesions with homogeneous, moderate enhancement. Inter-reader agreement was moderate to substantial for all vessel wall MRI characteristics (κ=0.46-0.86) and fair for collateral grading (κ=0.35). There was 11% inter-reader agreement for diagnosis on luminal imaging when compared with 82% for luminal imaging+vessel wall MRI (P<0.001). CONCLUSIONS: Vessel wall MRI can significantly improve the differentiation of moyamoya vasculopathies when combined with traditional imaging techniques.

Toward Quantifying the Prevalence, Severity, and Cost Associated With Patient Motion During Clinical MR Examinations.

PURPOSE: To assess the prevalence, severity, and cost estimates associated with motion artifacts identified on clinical MR examinations, with a focus on the neuroaxis. METHODS: A retrospective review of 1 randomly selected full calendar week of MR examinations (April 2014) was conducted for the detection of significant motion artifacts in examinations performed at a single institution on 3 different MR scanners. A base-case cost estimate was computed from recently available institutional data, and correlated with sequence time and severity of motion artifacts. RESULTS: A total of 192 completed clinical examinations were reviewed. Significant motion artifacts were identified on sequences in 7.5% of outpatient and 29.4% of inpatient and/or emergency department MR examinations. The prevalence of repeat sequences was 19.8% of total MRI examinations. The base-case cost estimate yielded a potential cost to the hospital of $592 per hour in lost revenue due to motion artifacts. Potential institutional average costs borne (revenue forgone) of approximately $115,000 per scanner per year may affect hospitals, owing to motion artifacts (univariate sensitivity analysis suggested a lower bound of $92,600, and an upper bound of $139,000). CONCLUSIONS: Motion artifacts represent a frequent cause of MR image degradation, particularly for inpatient and emergency department patients, resulting in substantial costs to the radiology department. Greater attention and resources should be directed toward providing practical solutions to this dilemma.

Using Hyaluronic Acid for Improving Vocal Function in a Prepubescent Boy With an Atrophied Right Vocal Fold.

OBJECTIVES: A single case study is reported of a child who underwent several surgical procedures as result of congenital grade III subglottic stenosis. The anterior aspect of the right vocal cord was damaged and underwent atrophy during one of these procedures. Now, an active 10-year-old, the patient has become increasingly aware of his vocal limitations on functional activities. Injection of hyaluronic acid into the vocal folds has been known to provide improved voice quality in adults although there are no known cases reported of this procedure in children. METHODS: This article reports voice outcomes after injection of hyaluronic acid into the Reinke's space in a single case study. Voice recordings were made before, after, and 1 month after injection. The voice recordings were subject to acoustic and perceptual analysis. RESULTS: Post and follow-up voice recordings demonstrate decreased jitter, shimmer, and harmonics-to-noise ratio. Perceptual evaluation indicates improved voice quality. CONCLUSION: Injection of hyaluronic acid in children who require voice augmentation is possible and may contribute to increased vocal function and improved voice outcomes.

Parent and Child Responses to the Pediatric Voice-Related Quality-of-Life Questionnaire.

OBJECTIVES: When assessing pediatric dysphonia, there are different approaches that can be taken in gathering a subjective view of the impact voice difficulties have on a child. Most valid questionnaires require parent-proxy reporting, although it has become increasingly important to gather the views of children themselves. This study reports a pilot study of an adaptation to the Pediatric Voice-Related Quality-of-Life Questionnaire (PVRQoL). METHODS: A total of 24 parent and child dyads were recruited from a tertiary pediatric voice clinic. Children were aged between 3 years and 8 months and 15 years and 3 months. Parents completed the existing PVRQoL questionnaire, whereas their children were given a child-adapted version. Follow-up completion of the child questionnaire was conducted after a 2-week period. RESULTS: There was a good correlation between the two time periods when children completed the adapted PVRQoL and also between parent and child responses. Of particular interest, however, was the different ratings on individual items by parents and their children with parents tending to overestimate the extent to which their children may be emotionally affected by their voice disorder. CONCLUSIONS: This study shows that children have much to tell about their own voice-related quality of life, so our conclusion is that they should also be self-assessed. The PVRQoL when adapted for use with children offers an additional insight that can be gathered in a relatively short timeframe and be considered with other assessments of vocal function.

The paediatric voice clinic.

BACKGROUND: Prevalence of paediatric voice disorders has been reported as 6-9% in children of school age. The appropriate diagnosis and management of paediatric voice disorders is essential for progress in education and psychosocial development. This paper presents a review of a UK tertiary paediatric voice clinic experience of referral patterns, diagnosis, management and socioeconomic variations. METHODS: An audit of 195 consecutive appointments (154 were new patients) between October 2009 and September 2013 at a monthly paediatric voice clinic based at the Royal Hospital for Sick Children in Glasgow. RESULTS: Of the 154 new patients, 86 were male and 68 were female. The age at first clinic appointment shows a trimodal peak at ages 5, 8 and 11 years. General practitioners were the main referral source (46%). Vocal cord nodules accounted for 52% of diagnoses with a male predominance. Clinic attendance was most common from Scottish Index of Multiple Deprivation groups 1 (most deprived) and 5 (least deprived). Analysis of the muscle tension dysphonia group indicates that they are more likely to come from social groups 4 or 5 (69%) and an older age group (mean age 10.4 years). DISCUSSION: A dedicated paediatric voice clinic is the optimal method for assessment, diagnosis and management of these patients. Diagnosis is possible on the majority of the patients in clinic, with the predominant pathology being vocal cord nodules that receive speech and language therapy. Socioeconomic group appears to have an influence on paediatric voice particularly vocal cord nodules and muscle tension dysphonia.

Angiographic perfusion imaging: real-time assessment of endovascular treatment for cerebral vasospasm.

BACKGROUND AND PURPOSE: Cerebral perfusion analysis is useful in the diagnosis and treatment of cerebral vasospasm. A new modality of real-time cerebral perfusion imaging and analysis has been developed using standard 2-dimensional angiography. We report our initial experience with this technique to assess response to therapy during endovascular vasospasm procedures. METHODS: Colorized angiographic perfusion maps were obtained immediately before and after endovascular vasospasm treatment. Semiquantitative perfusion parameters (cerebral blood flow, cerebral blood volume, mean transit time, and time to peak) were calculated from time-density curves obtained from intraarterial contrast injection. The effects of intraarterial vasospasm therapy were assessed. RESULTS: Eight vascular territories in 4 patients with vasospasm underwent interventional angiography and angiographic perfusion analysis. Pretreatment perfusion maps demonstrated variable perfusion deficits in specific vascular territories. After endovascular treatment in 6 vessels, improvement was seen to varying degrees in both angiographic appearance and perfusion parameters. Clinical improvement and reduction in transcranial Doppler velocity was also observed. CONCLUSIONS: Real-time angiographic perfusion imaging is feasible during endovascular procedures for vasospasm. Perfusion analysis may aid in assessment of efficacy of the intervention. Comparison with traditional perfusion imaging is needed to validate this technique.

Articular cartilage degeneration in the contralateral non-surgical temporomandibular joint in mice with a unilateral partial discectomy.

OBJECTIVE: The objective was to characterize the contralateral non-surgical temporomandibular joint (TMJ) in mice that had an opposing osteoarthrosis(OA)-like joint induced by unilateral partial discectomy. METHODS: TMJs on one side in mice were subjected to partial discectomy. Both surgical and contralateral non-surgical TMJs were collected at 4, 8, 12 and 16 weeks post-surgery for histological examination. The morphology of the articular cartilage of the condyle was evaluated using a scoring system. RESULTS: A progression of articular cartilage degeneration was seen in the TMJs following unilateral partial discectomy, including increased proteoglycan staining in the extracellular matrix at 4 weeks, the appearance of chondrocyte clusters at 8 weeks, reduced proteoglycan staining and fibrillation at 12 weeks and the loss of articular cartilage at 16 weeks. In the contralateral non-surgical TMJs, increased proteoglycan staining occurred in the articular cartilage of the condyle at 8 weeks and continued to age. CONCLUSION: The result indicated that OA-like changes in one TMJ by partial discectomy could initiate early-onset articular cartilage degeneration in the contralateral non-surgical TMJ in mice.