Decannulation protocol for short term tracheostomy in pediatric head and neck tumor patients.

BACKGROUND: While the majority of pediatric tracheostomies are performed in the setting of chronic and complex medical comorbidities, perioperative tracheostomies following head and neck tumor ablation are generally short-term. Deliberate planning is required for decannulation in this setting and no published protocols currently exist. Our study outlines a management strategy for short-term tracheostomy in pediatric patients following head and neck surgery. METHODS: A retrospective study of pediatric head and neck tumor patients undergoing tracheostomy was performed at a quaternary children's hospital from February 1, 2016 to December 31, 2018. Charts were reviewed for demographics, surgical operation, relevant tracheostomy-related complications, and time to decannulation. RESULTS: Eleven patients with a mean age of 10.4 years (st.dev. 6.7, range: 0.5-23) underwent tracheostomy during their primary ablative/reconstructive surgery. Trans-tracheal pressure monitoring helped direct the need for tracheostomy downsizing and readiness for capping trials. All patients were decannulated before hospital discharge after a mean of 12.8 days (st.dev. 2.5, range: 9-18) and were discharged after a mean of 14.8 days (st.dev. 2.5, range: 11-20). CONCLUSION: Pediatric head and neck surgery patients can be quickly and safely decannulated with an instructive protocol and multidisciplinary care.

Videofluoroscopic Swallow Studies and Diagnostic Outcomes in Otherwise Healthy Infants With Dysphagia.

OBJECTIVES: To evaluate videofluoroscopic swallow study (VFSS) findings in infants with dysphagia and without prior diagnoses, and to characterize the outcomes and any diagnoses that follow. METHODS: A chart review of all pediatric patients who received a VFSS at a tertiary children's hospital from November 2008 to March 2017 was performed. RESULTS: There were 106 infants (57 males and 49 females) with 108 VFSS. VFSS was normal in 18 (16.98%) infants. Regarding airway protection, 50 (47.17%) infants had laryngeal penetration, and 8 (7.55%) had tracheal aspiration; 3 (2.83%, 37.5% of all aspirators) exhibited silent aspiration. Of the 75 infants with minimum 2-year follow-up, 35 (46.67%) had no sequelae of disease and received no diagnoses. The most common diagnoses and pathologic sequelae were gastroesophageal reflux (n = 18, 24.00%), asthma (n = 8, 10.67%), laryngomalacia (n = 6, 8.00%), and tracheomalacia (n = 4, 5.33%), all consistent with United States pediatric data on prevalence. All infants (n = 51) with follow-up for dysphagia had resolution of symptoms within 9 months from VFSS order date. CONCLUSIONS: Otherwise healthy infants may show signs of dysphagia and not develop later illness. Parents can thus be counseled on the implications of dysphagia in a previously healthy infant. Our findings provide comparative statistics for future research in pediatric dysphagia.

Vocal Fold Movement and Silent Aspiration After Congenital Heart Surgery.

OBJECTIVES/HYPOTHESIS: Infants who undergo congenital heart surgery are at risk of developing vocal fold motion impairment (VFMI) and swallowing difficulties. This study aims to describe the dysphagia in this population and explore the associations between surgical complexity and vocal fold mobility with dysphagia and airway protection. STUDY DESIGN: Retrospective chart review. METHODS: This is a retrospective chart review of infants (age <12 months) who underwent congenital heart surgery between 7/2008 and 1/2018 and received a subsequent videofluoroscopic swallow study (VFSS). Demographic information, Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) category of each surgery, vocal fold mobility status, and VFSS findings were collected and analyzed. RESULTS: Three hundred and seventy-four patients were included in the study. Fifty-four percent of patients were male, 24% were premature, and the average age at the time of VFSS was 59 days. Sixty percent of patients had oral dysphagia and 64% of patients had pharyngeal dysphagia. Fifty-one percent of patients had laryngeal penetration and 45% had tracheal aspiration. Seventy-three percent of these aspirations were silent. There was no association between surgical complexity, as defined by the STAT category, and dysphagia or airway protection findings. Patients with VFMI after surgery were more likely to have silent aspiration (odds ratio = 1.94, P < .01), even when adjusting for other risk factors. CONCLUSION: Infants who undergo congenital heart surgery are at high risk for VFMI and aspiration across all five STAT categories. This study demonstrates the high prevalence of silent aspiration in this population and the need for thorough postoperative swallow evaluation. LEVEL OF EVIDENCE: 4 Laryngoscope, 132:701-705, 2022.

Videofluoroscopic Swallow Study Findings and Correlations in Infancy of Children with Cerebral Palsy.

OBJECTIVES: Cerebral palsy (CP) in infants can affect global motor function and lead to swallowing difficulties. This study aims to characterize oral and pharyngeal swallowing dynamics in infancy of patients later diagnosed with CP and to determine if swallow study performance in early infancy is associated with later CP severity and characteristics. METHODS: This is a retrospective chart review of infants who underwent videofluoroscopic swallow studies (VFSS) between 6/2008 and 10/2018 at a tertiary children's hospital, and were later diagnosed with CP. Demographic data, CP characteristics and metrics, and VFSS findings were collected and analyzed. RESULTS: There were 66 patients included in this study. The average age at the time of VFSS was 4 months (range: 0.3-12 months), 42% of patients were female, and 50% of patients were born premature. In our sample, 86% of patients presented with oral dysphagia, and 76% with pharyngeal dysphagia. Laryngeal penetration in isolation was seen in 39% of patients, and tracheal aspiration was seen in 38% of patients. Of these tracheal aspiration events, 64% were silent. At the time of VFSS, 58% of patients had a nasogastric tube, 12% had a gastrostomy tube, and 3% had a prior hospitalization for pneumonia. Rates of penetration and aspiration in early infancy did not consistently correlate with prematurity, type of CP (spastic, non-spastic, or mixed), degree of paralysis (quadriplegic, hemiplegic, or diplegic), or severity of Gross Motor Function Classification System (GMFCS) score. CONCLUSION: While there was not a consistent correlation of swallowing dynamics in infancy with later gross motor categorizations of CP, the results of this retrospective review highlight the essential role of early clinical and videofluoroscopic swallowing evaluations to identify oral and pharyngeal swallowing dysfunction in this patient population.

Airway protection & patterns of dysphagia in infants with down syndrome: Videofluoroscopic swallow study findings & correlations.

INTRODUCTION: Down syndrome is a genetic condition that affects 1:737 births. Along with cardiac, otolaryngologic, and developmental anomalies, infants with Down syndrome can have swallowing difficulties resulting in respiratory infections. This study aims to characterize the airway protection and dysphagia seen in infants with Down syndrome. METHODS: This is a retrospective chart review of infants with Down syndrome who underwent videofluoroscopic swallow studies (VFSS) from 2008 to 2018 at a tertiary children's hospital. Demographic data and VFSS findings were collected. RESULTS: 89.8% (114/127) of infants presented with at least one element of oral dysphagia, while 72.4% (92/127) had at least one element of pharyngeal dysphagia. Sucking skills were classified as abnormal in 63.7% of the patients and bolus formation-control was determined to be deficient (abnormal) in 62.2% of the patients. Oral residuals were present in 37.8% of the patients. With regard to pharyngeal phase, the swallow initiation was considered abnormal in 53.5% of the patients. Pharyngeal residue was present in 17.3% and pharyngo-nasal reflux was present in 27.5% of the patients. CONCLUSIONS: Swallowing assessments in infants with Down syndrome suspected of dysphagia should be considered, especially in those with any alterations in pulmonary health.

Patterns of Dysphagia and Airway Protection in Infants with 22q11.2-Deletion Syndrome.

OBJECTIVE: 22q11.2-deletion syndrome is a genetic condition that affects 1:3000 births. In addition to cardiac anomalies and immunosuppression, individuals with 22q11.2-deletion syndrome can have feeding difficulties from birth resulting in failure to thrive and infections. This study aims to characterize the dysphagia seen in infants with 22q11.2-deletion syndrome. METHODS: This is a retrospective chart review of infants with 22q11.2-deletion syndrome who underwent videofluoroscopic swallow studies (VFSS) from June 1, 2008 to January 1, 2018 at a tertiary children's hospital. Demographic data and VFSS findings were collected. RESULTS: Forty-four patients were identified, 52% were females, and mean age at VFSS was 71 days. In their lifetime, 30% of the patients had at least 1 episode of pneumonia, 66% had NG-tube placement and 41% required G-tube placement. 93% had oral-phase dysphagia, and 89% had pharyngeal-phase dysphagia. Twenty-two patients (50%) demonstrated evidence of penetration. Eighteen patients (41%) showed tracheal aspiration. Of the patients that showed tracheal aspiration, 83% of them aspirated "silently." Three patients (7%) had upper esophageal sphincter (UES) opening dysfunction. CONCLUSION: Vast majority of the infants with 22q11.2-deletion syndrome referred for swallow studies demonstrated evidence of dysphagia in both oral and pharyngeal phases with deficits in swallow physiology not yet documented in other studies. Importantly, more than 80% of these infants showed evidence of "silent" tracheal aspiration, which can lead to recurrent pneumonia and significant morbidity if overlooked. Prompt recognition is paramount in these infants to intervene early and reduce long-term complications and also develop targeted interventions. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:2532-2536, 2020.

The effect of a speaking valve on laryngeal aspiration and penetration in children with tracheotomies.

OBJECTIVES/HYPOTHESIS: Alterations in swallowing can occur after tracheotomy and can result in varying degrees of aspiration. In tracheotomized adult patients, use of a Passy Muir Speaking Valve (PMV) has been shown to decrease laryngeal penetration and aspiration of foods and liquids. The objective of this study was to determine if the PMV has a similar effect on laryngeal penetration and aspiration in tracheotomized children. STUDY DESIGN: This is a prospective case-control study. METHODS: Pediatric patients with tracheotomies who were able to tolerate the PMV were identified. Modified barium swallow (MBS) was performed with and without the PMV. Two consistencies, thin liquids and purées, were used. Two speech language pathologists (SLPs), who were blinded to the PMV status, reviewed the recorded MBSs. Three swallows of each consistency were graded on an 8 point Penetration-Aspiration Scale. Residue in the vallecula, piriform sinuses, and posterior pharyngeal wall was graded. RESULTS: Twelve patients were included for analysis. Laryngeal penetration and aspiration was decreased with purées over liquids (P = 0.5 and P = 0.005, respectively) with either the sham valve or the PMV. The presence of the PMV decreased piriform sinus residue (P = 0.01); however, it did not demonstrate a decrease in laryngeal aspiration or penetration. CONCLUSION: Unlike in adults, the presence of PMV did not decrease laryngeal aspiration or penetration in children with tracheotomies. It did, however, improve piriform sinus residue. LEVEL OF EVIDENCE: 3b.

Comparison of Spanish, English, and Bilingual Children's Performance Across Semantic Tasks.

PURPOSE: This study investigated predominantly Spanish-speaking, predominantly English-speaking, and Spanish-English bilingual children's performance on a battery of semantic tasks. METHOD: Six semantic tasks (associations, characteristic properties, categorization, functions, linguistic concepts, and similarities and differences) were developed in Spanish and English. The tasks contained comparable items but were not direct translations of each other. Each task consisted of expressive and receptive items. Predominantly Spanish-speaking children completed the tasks in Spanish, predominantly English-speaking children completed the tasks in English, and bilingual children completed the tasks in Spanish and English. RESULTS: Children in all three groups achieved similar average levels of performance on the assessment battery. However, there were differences in the patterns of performance for English and Spanish, as well as group performance differences when compared in the same language. CLINICAL IMPLICATIONS: These findings highlight the importance of testing bilingual children in both of their languages and across a variety of semantic tasks in order to gain insight into bilingual children's semantic knowledge.