Management of noncleft velopharyngeal insufficiency.

PURPOSE OF REVIEW: Velopharyngeal insufficiency in the absence of an overt cleft-palate is a less common and often missed cause of a resonance disorder. The purpose of this manuscript is to provide the reader with an overview of the clinical assessment. Highlight the need for multidisciplinary involvement. Discuss the process of decision-making related to a repair and finally comment on the preoperative, intra-operative, and postoperative considerations. RECENT FINDINGS: With the advent of small calibre videonasendoscopes, evaluation of the size, location, and closure pattern of the velopharyngeal gap has improved the surgeons' ability to provide a tailored repair. Evolutions in technique including posterior pharyngeal wall augmentation and buccal flap advancement in palatal lengthening have all increased the options available to the patient and treating team. SUMMARY: Multidisciplinary assessment by trained specialist from speech and language pathology and surgery remain the cornerstone in the evaluation and management of this patient cohort. Many have a chromosomal anomaly that should be tested for and managed accordingly. These patients are often diagnosed late and have developed additional compensatory speech disorders that often need to be addressed following repair of the palate. Targeted thoughtful assessment will allow for a greater likelihood of successful repair.

Fiberoptic Endoscopic Evaluation of Swallowing in Infants and Children: Protocol, Safety, and Clinical Efficacy: 25 Years of Experience.

BACKGROUND: The application of fiberoptic endoscopic evaluation of swallowing (FEES) in the pediatric dysphagia protocol requires specialized knowledge of pediatric conditions that result in dysphagia, recognition of normal and abnormal laryngopharyngeal anatomy and function across ages, and the ability to identify maturational changes in anatomy and function of the aerodigestive tract that pertain to airway protection and swallowing function. METHODS: Over the past 25 years, we have performed over 7,000 collaborative Otolaryngology and Speech-Language Pathology FEES examinations in patients ranging from 2 days of age to young adults. During this time period, we have monitored the safety of the procedure, explored the feasibility and utility of FEES across conditions, compared and contrasted FEES to the videofluoroscopic evaluation of swallowing (VFSS), and developed specific pediatric FEES protocols with operational definitions for identification and interpretation of swallowing parameters. RESULTS: FEES has proved to be a safe procedure in patients across ages. There have been no significant adverse events. FEES is comparable to the VFSS in the assessment of events before and after the swallow. It provides unique information regarding laryngopharyngeal anatomy and function, airway protection integrity, sensory threshold, and secretion management ability, as well as pharyngeal swallowing dynamics and the efficacy of compensatory swallowing strategies. CONCLUSIONS: There are specific indications and contraindications for pediatric FEES, and unique components that characterize the pediatric FEES protocols across ages and conditions. FEES procedures performed jointly by an Otolaryngologist and Speech-Language pathologist offer a team approach to interpretation and management recommendations.

Duration and extent of dysphagia following pediatric airway reconstruction.

OBJECTIVE: Patients who undergo open airway reconstruction procedures are likely to experience some degree of post-operative dysphagia. This retrospective review describes the duration of post-operative dysphagia and the use of compensatory strategies in a group of 30 pediatric patients. METHODS: A retrospective chart review of pediatric patients referred for post-operative swallowing assessment following airway reconstruction during a six-month period was completed. Age, sex, surgical procedure, stent type, co-morbid factors, duration of dysphagia, and use of compensatory dietary modifications and swallowing strategies was summarized and compared. RESULTS: Dysphagia was generally of short duration (1-5 days) in patients undergoing single stage procedures with anterior or anterior/posterior grafts. Duration of swallowing difficulty was increased in patients undergoing posterior grafts in combination with T tubes (10-14 days). The longest duration of difficulty (>2 weeks) occurred in patients who had anterior and posterior grafting with T tubes, combined with additional procedures such as vocal fold lateralization, epiglottic petiole repositioning, and/or arytenoidectomy. There was a greater likelihood of oral feeding difficulty post-operatively in patients presenting with pre-operative feeding issues such as oral aversion or specific texture refusal, and the pre-morbid need for supplemental tube feeding to supplement oral intake. Compensatory swallowing strategies were effective in decreasing aspiration associated with swallowing in oral feeders post-operatively, and in facilitating return to baseline swallowing skills. CONCLUSIONS: The duration of dysphagia overall was increased in patients undergoing anterior/posterior grafts in conjunction with in-dwelling T tubes, especially when combined with additional procedures. Compensatory strategies to assist with swallowing were found to be effective in the post-operative phase and included the use of a modified supraglottic swallowing sequence to assist with compensatory airway closure during swallowing in conjunction with diet modifications. Post-operative feeding difficulty occurred in patients with pre-existing feeding issues such as oral aversion and/or texture resistance regardless of reconstructive surgical procedure type.

Multicenter interrater and intrarater reliability in the endoscopic evaluation of velopharyngeal insufficiency.

OBJECTIVE: To explore interrater and intrarater reliability (R (inter) and R (intra), respectively) of a standardized scale applied to nasoendoscopic assessment of velopharyngeal (VP) function, across multiple centers. DESIGN: Multicenter blinded R (inter) and R (intra) study. SETTING: Eight academic tertiary care centers. PARTICIPANTS: Sixteen otolaryngologists from 8 centers. MAIN OUTCOME MEASURES: Raters estimated lateral pharyngeal and palatal movement on nasoendoscopic tapes from 50 different patients. Raters were asked to (1) estimate gap size during phonation and (2) note the presence of the Passavant ridge, a midline palatal notch on the nasal surface of the soft palate, and aberrant pulsations. Primary outcome measures were R (inter) and R (intra) coefficients for estimated gap size, lateral wall, and palatal movement; kappa coefficients for the Passavant ridge, a midline palatal notch on the nasal soft palate, and aberrant pulsations were also calculated. RESULTS: The R (inter) coefficients were 0.63 for estimated gap size, 0.41 for lateral wall movement, and 0.43 for palate movement; corresponding R (intra) coefficients were 0.86, 0.79, and 0.83, respectively. Interrater kappa values for qualitative features were 0.10 for the Passavant ridge; 0.48 for a notch on the nasal surface of the soft palate, 0.56 for aberrant pulsations, and 0.39 for estimation of gap size. CONCLUSIONS: In these data, there was good R (intra) and fair R (inter) when using the Golding-Kushner scale for rating VP function based on nasoendoscopy. Estimates of VP gap size demonstrate higher reliability coefficients than total lateral wall, mean palate estimates, and categorical estimate of gap size. The reliability of rating qualitative characteristics (ie, the presence of the Passavant ridge, aberrant pulsations, and notch on the nasal surface of the soft palate) is variable.

Pediatric salivary gland lesions.

The salivary glands comprise three main pairs of glands (ie, the parotid, the submandibular, and the sublingual) and a number of minor glands found in the mucosa of the upper aerodigestive tract. Lesions may be inflammatory or obstructive in nature or may stem from granulomatous or neoplastic disease. As such, establishing a definitive diagnosis is often quite challenging. This article reviews widely used diagnostic approaches and briefly describes various salivary gland lesions within an etiologic framework.

Advances in the evaluation and management of pediatric dysphagia.

PURPOSE OF REVIEW: Feeding and swallowing problems in the pediatric population, commonly referred to as pediatric dysphagia, are often complex. Multiple disciplines are frequently involved in both the evaluation and the management of symptoms exhibited by an increasing number of infants and children. The efficacy of commonly employed diagnostic and treatment strategies has been largely unexplored, although there has been a steadily increasing amount of research specific to pediatric dysphagia. Recent research efforts are reviewed which contribute data necessary for development of evidence-based evaluation and management methods. RECENT FINDINGS: Research contributions over the past year have included continued work in the classification and categorization of the widely varied causes of pediatric dysphagia. Research efforts have also focused on objective data of swallowing mechanics by use of diagnostic tools such as videofluoroscopy, endoscopy, and electromyography. Recent advances in approaches to the management of pediatric dysphagia symptoms secondary to achalasia and eosinophilic esophagitis are discussed. SUMMARY: Research that contributes to the base of knowledge regarding diagnosis and treatment of pediatric dysphagia has been consistently accumulating in recent years, yet much work remains to be done. Continued research studies, both retrospective and prospective in nature, are clearly needed to continue to build evidence-based evaluation and treatment protocols for pediatric dysphagia.