Development and validation of the caregiver Burden from infant home NGT care instrument.

OBJECTIVE: To design and validate an age and condition-specific health status instrument to best reflect the parental experience caring for these children with complex needs and home Nasogastric Tube (NGT) placement. STUDY DESIGN: Combined Qualitative and Quantitative design, testing and implementation for item production and reduction, followed by formal validation by evaluating validity, reliability, and establishing a clinically meaningful change score. SETTINGS: Tertiary care, multi-disciplinary aerodigestive center. PARTICIPANTS: All caregivers whose infant met criteria for eligibility for discharge home from the NICU or Special Care Nursery (SCN) with NGT in place were offered inclusion in this group. Intervention/Exposure: Structured qualitative interviews of these caregivers to explore and define these concepts and domains, to item generate and then reduce, and then psychometric analyses. METHODS: Structured, moderated qualitative interviews with parents/caregivers of children who have undergone home NGT care of their children for item creation, design, and then reduction. Reliability was assessed by Cronbach alpha analysis. Construct validity and clinically meaningful change score was assessed using various query methods. MAIN OUTCOME MEASURES: Cronbach's alpha to assess reliability, a priori hypotheses validity analyses, and minimally important clinical difference calculation. RESULTS: Scaled scores of this condition specific instrument ranged from 14 to 74 where higher scores indicate better QOL related to managing the NGT. Cronbach's alpha with all 14 items was 0.93. Validity was assessed by a self-assessment question to discriminate between change (95% CI: 8.5-14.1; p < 0.0001) as well as by other comparators to identify the instrument's ability to discriminate among populations where parents felt a difference in experience. The minimally important difference was calculated at 18 points. CONCLUSION: This represents the initial validation of the first condition and age-specific health status instrument to assess parent experience of caring for infants requiring a home NGT for dysphagia.

The Effectiveness of Slightly Thick Liquids for Improving Swallowing in Bottle-Fed Children With Aerodigestive Concerns.

Purpose: Strategies for facilitating safe and functional bottle feeding in children with dysphagia include selecting nipples that reduce flow rate, pacing, altered positioning, and thickening liquid consistencies. We aimed to determine the impact of slightly thick liquids on swallowing through retrospective review of a convenience sample of clinical videofluoroscopic swallowing studies (VFSS) from 60 bottle-fed children (21 boys and 39 girls, mean age of 9.9 months) referred due to suspected aspiration. Method: Eligible VFSS exams were those in which the child swallowed both thin and slightly thick barium (40% w/v Varibar barium) using the same nipple. VFSS sequences (i.e., uninterrupted portions of the VFSS recording) were randomly assigned in duplicate for rating by trained raters; discrepancies were resolved by consensus. Parameters measured included number of swallows/sequence, sucks/swallow, swallow and sequence duration, number and timing of penetration or aspiration events, laryngeal vestibule closure integrity, and pharyngeal residue. Chi-square tests, linear mixed-model analyses of variance, and Wilcoxon signed-ranks tests identified consistency effects. Results: There were no aspiration events in these recordings. Slightly thick liquids resulted in significantly fewer penetration events (p < .05), increased sucks/swallow, fewer swallows/sequence, and longer swallow and sequence durations. The number of children with ≥ 1 sequence showing pyriform sinus residue was significantly higher with slightly thick liquids. Conclusions: Slightly thick liquids can be effective in reducing penetration in bottle-fed children with dysphagia. However, slightly thick liquids may also lead to a safety-efficiency trade-off, with increased risk of pyriform sinus residue. Thickening for children with dysphagia should be considered only when other approaches are not effective. Overthickening should be avoided to limit negative impact on swallowing efficiency.

Overcoming language barriers in pediatric care: a multilingual, AI-driven curriculum for global healthcare education.

Background: Online medical education often faces challenges related to communication and comprehension barriers, particularly when the instructional language differs from the healthcare providers' and caregivers' native languages. Our study addresses these challenges within pediatric healthcare by employing generative language models to produce a linguistically tailored, multilingual curriculum that covers the topics of team training, surgical procedures, perioperative care, patient journeys, and educational resources for healthcare providers and caregivers. Methods: An interdisciplinary group formulated a video curriculum in English, addressing the nuanced challenges of pediatric healthcare. Subsequently, it was translated into Spanish, primarily emphasizing Latin American demographics, utilizing OpenAI's GPT-4. Videos were enriched with synthetic voice profiles of native speakers to uphold the consistency of the narrative. Results: We created a collection of 45 multilingual video modules, each ranging from 3 to 8 min in length and covering essential topics such as teamwork, how to improve interpersonal communication, "How I Do It" surgical procedures, as well as focused topics in anesthesia, intensive care unit care, ward nursing, and transitions from hospital to home. Through AI-driven translation, this comprehensive collection ensures global accessibility and offers healthcare professionals and caregivers a linguistically inclusive resource for elevating standards of pediatric care worldwide. Conclusion: This development of multilingual educational content marks a progressive step toward global standardization of pediatric care. By utilizing advanced language models for translation, we ensure that the curriculum is inclusive and accessible. This initiative aligns well with the World Health Organization's Digital Health Guidelines, advocating for digitally enabled healthcare education.

Aspiration does not mean the end of a breast-feeding relationship.

OBJECTIVE: Breastfeeding is widely recommended as optimal nutrition for infants. However, there are no known publications on the impact of prandial aspiration of breast milk fed infants with dysphagia. The goal of this study was to assess pulmonary outcomes in infants with dysphagia who were given medical clearance for intake of breast milk. METHODS: This retrospective cohort study included review of 80 infants examined between August 2016 to March 2021. Patients were evaluated by an interdisciplinary team of providers in a tertiary pediatric aerodigestive center. Patient inclusion criteria included a VFSS with documented aspiration or penetration with thin liquids. Participants met inclusion criteria if given medical clearance for intake of breast milk despite aspiration risk. Pulmonary health was monitored for three months following medical clearance for the consumption of breast milk. Pulmonary illness was defined as development of bronchiolitis, wheezing, unexplained stridor during feeding, croup, pneumonia, or persistent bacterial bronchitis requiring medical intervention. RESULTS: Forty-three males (54%) and 37 females (46%) enrolled in the study with an age range of 1 month-6 months corrected age. Mean age at initial VFSS was 3.6 months. Twenty-six out of 80 (32.5%) had a report of a mild cough but did not require intervention. Eight out of 80 (10%) received a diagnosis of a pulmonary illness. Seventy-two out of 80 (90%) did not report pulmonary illness. CONCLUSION: This pilot study reveals that the majority (90%) of this single institution, small sample size cohort of breast milk fed infants with documented oropharyngeal dysphagia remained healthy despite continued intake of breast milk. Prospective investigation is warranted to follow pulmonary health outcomes longitudinally and a head to head comparative study would be helpful to identify whether there were indeed significant changes to pulmonary health according to differential feeding regimens offered and followed.

Carotid artery mobilization prior to pharyngeal flap inset for patients with 22q11.2 deletion syndrome.

The management of velopharyngeal insufficiency (VPI) in patients with 22q11.2 deletion syndrome (22q11DS) poses a significant clinical challenge due to presence of a large velopharyngeal gap and a relatively high rate of internal carotid artery (ICA) medialization. To our knowledge, we are the first group to have successfully managed VPI in a series of seven pediatric patients with 22q11DS with medialized ICAs via a novel surgical technique involving carotid artery mobilization followed by pharyngeal flap insertion. Thus far, we have found this technique to be reliably safe with no significant morbidity and caregivers have reported postoperative improvement in speech, swallowing and nasal regurgitation symptoms. Herein, we provide a detailed description of our novel surgical approach, including an instructional video, for correction of VPI in patients with medialized ICAs, who have previously had limited management options.

Factors associated with frenotomy after a multidisciplinary assessment of infants with breastfeeding difficulties.

OBJECTIVE: Frenotomy for ankyloglossia has increased nearly 10-fold over the past few decades despite insufficient evidence that the procedure improves breastfeeding outcomes. There is no universally accepted method for identifying patients who may benefit from the procedure. The objective of this study is to determine if comprehensive feeding evaluations and targeted interventions can identify children who should undergo procedures, and to identify factors associated with lip or tongue frenotomy to treat breastfeeding difficulties. METHODS: This observational quality improvement study followed infant-mother dyads between March 2018 and December 2019 referred to our tertiary care center for breastfeeding difficulties. Speech and language pathologists performed comprehensive feeding evaluations on infants prior to surgical consultation for frenotomy. Infants' oral anatomy and function and their ability to breast and bottle feed were assessed, and techniques for mothers to address feeding difficulties without a procedure were offered prior to surgical consultation. Infants either found success over a short observation period or underwent procedures (lip and/or tongue frenotomy). RESULTS: 153 patients (mean age 47.0 days (stdev 39.0 days, 56.2% male) were referred for surgical division of the lingual frenulum. Following development of a program utilizing pediatric speech language pathologists to perform feeding evaluations prior to surgical consultation, 69.9% of patients subsequently did not undergo surgical procedures. 11 (23.9%) underwent labial frenotomy alone and 30 (65.2%) underwent both labial and lingual frenotomies. Frenotomy was associated with significantly increased worry subscale of the Feeding Swallow Impact Survey (FSIS) and decreased mean Breastfeeding Self Efficacy Scale score (p = 0.0001, p = 0.006, respectively). Tongue appearance was significantly associated with having a procedure, while lip appearance was not. The Bristol Breastfeeding Assessment Tool (BBAT) was lower in children undergoing tongue and/or lip frenotomy (p = 0.0006), while the Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF) appearance and function scores were lower in children undergoing lingual frenotomy with or without lip frenotomy (p = 0.0008, p = 0.0009, respectively). CONCLUSIONS: The majority of patients referred for ankyloglossia may benefit from nonsurgical intervention strategies based on findings from comprehensive feeding evaluation. Frenotomy is associated with higher maternal feeding-related worry and reduced breastfeeding self-efficacy scores. While tongue appearance is associated with frenotomy, functional assessment is critical for identifying patients who may also benefit from lip frenotomy.

A Sustainable and Scalable Multidisciplinary Airway Teaching Mission: The Operation Airway 10-Year Experience.

OBJECTIVE: To address whether a multidisciplinary team of pediatric otolaryngologists, anesthesiologists, pediatric intensivists, speech-language pathologists, and nurses can achieve safe and sustainable surgical outcomes in low-resourced settings when conducting a pediatric airway surgical teaching mission that features a program of progressive autonomy. STUDY DESIGN: Consecutive case series with chart review. SETTING: This study reviews 14 consecutive missions from 2010 to 2019 in Ecuador, El Salvador, and the Dominican Republic. METHODS: Demographic data, diagnostic and operative details, and operative outcomes were collected. A country's program met graduation criteria if its multidisciplinary team developed the ability to autonomously manage the preoperative huddle, operating room discussion and setup, operative procedure, and postoperative multidisciplinary pediatric intensive care unit and floor care decision making. This was assessed by direct observation and assessment of surgical outcomes. RESULTS: A total of 135 procedures were performed on 90 patients in Ecuador (n = 24), the Dominican Republic (n = 51), and El Salvador (n = 39). Five patients required transport to the United States to receive quaternary-level care. Thirty-six laryngotracheal reconstructions were completed: 6 single-stage, 12 one-and-a-half-stage, and 18 double-stage cases. We achieved a decannulation rate of 82%. Two programs (Ecuador and the Dominican Republic) met graduation criteria and have become self-sufficient. No mortalities were recorded. CONCLUSION: This is the largest longitudinal description of an airway reconstruction teaching mission in low- and middle-income countries. Airway reconstruction can be safe and effective in low-resourced settings with a thoughtful multidisciplinary team led by local champions.

Long-term swallowing outcomes following type 1 laryngeal cleft injection.

INTRODUCTION: Interarytenoid injection augmentation (IIA) during initial diagnostic endoscopy for aspiration and dysphagia has been described as both a diagnostic and therapeutic technique in the evaluation of type 1 laryngeal cleft (LC-1). IIA is additionally hypothesized to be a temporizing measure that facilitates improvement of swallowing function and potentially obviates the need for future formal endoscopic suture repair of LC-1. However, long-term (>6 month) outcomes of IIA for LC-1 remain largely unknown. The objective of this study was to evaluate the effect of IIA on long-term swallowing outcomes and need for formal endoscopic suture repair in patients with LC-1. METHODS: This is a retrospective cohort study of patients age ≤24 months with pharyngeal phase dysphagia on preoperative videofluoroscopic swallow study (VFSS) who underwent IIA for LC-1 during diagnostic laryngoscopy and bronchoscopy at a single tertiary care academic subspecialty hospital from June 2017 to May 2018. Included patients underwent VFSS within 30 days of IIA and had documented SLP follow up at 6 months or more post-procedure. Exclusion criteria included prior cleft repair, gastrostomy tube dependence, additional procedures at the time of IIA, or lack of documented follow up. A total of 34 patients underwent LC-1 during study period with 24 included in final analyses. The primary outcome measure was improvement in safely swallowed consistency at 6 months or greater following injection. Secondary outcomes included need for formal suture LC-1 repair following IIA and comparison of 30-day and long-term swallowing function. RESULTS: Median [range] age at injection was 15.3 [10.3-19.1] months and 50% were female (n = 12). Improvement was noted in 12 (50%) patients within 30 days of IIA, with 11 of 12 demonstrating sustained improvement at long-term follow up (10.3 [9.3-14.0] months). Among all patients, 15 of 24 (63%) demonstrated improvement compared to preoperative baseline. Six of 24 (25%) required formal suture repair of LC-1. CONCLUSIONS: IIA is a safe procedure that may result in both immediate and long-term improvement in dysphagia in select patients with LC-1. Additional studies are required to determine impact of IIA on pulmonary complications and hospital utilization and as well as patient- and caregiver-related outcome measures.

Association of Feeding Evaluation With Frenotomy Rates in Infants With Breastfeeding Difficulties.

IMPORTANCE: Inpatient surgical release of lingual frenulums rose 10-fold between 1997 and 2012 despite insufficient evidence that frenotomy for ankyloglossia is associated with improvements in breastfeeding. Clear indications for surgical release remain murky, and best practice guidelines have yet to be developed. OBJECTIVE: To determine whether infants referred for frenotomy to treat breastfeeding difficulties should undergo procedures after comprehensive feeding examination, during which the primary cause of feeding issues was identified, and targeted intervention was provided. DESIGN, SETTING, AND PARTICIPANTS: This observational quality improvement study followed mother-infant dyads between March and December of 2018 who were referred to our tertiary care center for difficulty with breastfeeding. All infants underwent a comprehensive feeding evaluation by speech and language pathologists who examined the infants' ability to breastfeed prior to a surgical consultation for initial frenotomy. Data analysis was performed between January 2019 and May 2019. INTERVENTIONS: A multidisciplinary feeding evaluation that examined infants' oral structure and function and their ability to breastfeed and that offered techniques for mothers to address any feeding difficulties prior to surgical intervention was developed. Infants either found success in feeding and weight gain through this program or underwent procedures. MAIN OUTCOMES AND MEASURES: The primary outcome was the percentage of frenotomy procedures following implementation of a multidisciplinary feeding team evaluation. The secondary outcome was the percentage of infants referred for lingual frenotomy who later had either combined lingual and labial frenotomy or labial frenotomy alone. RESULTS: Included in the study were 115 patients (median age, 34 days [interquartile range, 19-56 days], 68 (59%) were male) referred for surgical division of the lingual frenum. Following the development of a program with feeding examination with a pediatric speech and language pathologist, 72 (62.6%) patients subsequently did not undergo surgical procedures. Although all of the referrals were for lingual frenotomy, 10 (8.7%) underwent labial frenotomy alone and 32 (27.8%) underwent both labial and lingual frenotomy. CONCLUSIONS AND RELEVANCE: The majority of patients referred for ankyloglossia may benefit from alternative intervention strategies following comprehensive feeding evaluation. Close collaboration and formation of multidisciplinary teams are imperative for treating these children.

Pharyngeal flap using carotid artery mobilization in 22q11.2 deletion syndrome with velopharyngeal insufficiency.

INTRODUCTION: 22q11.2 deletion syndrome is the most common microdeletion syndrome in children. Many patients with this disease develop craniofacial defects including cleft palate, bifid uvula, and velopharyngeal insufficiency. Our study adds to the current body of literature by describing a novel technique of carotid mobilization performed in conjunction with pharyngeal flap surgery in patients with extensive medialization of the carotid artery. METHODS: Carotid artery mobilization followed by insertion of a superiorly based pharyngeal flap was performed on two patients, a 10-year-old girl and a 5-year-old boy, with 22q11.2 deletion syndrome concurrent with velopharyngeal insufficiency. RESULTS: Neither patient experienced significant post-operative issues. Following the procedure, parents of both patients noted significant speech and voice improvement. Both patients had improvements in VPI Effects On Life Outcome (VELO) scores, nasometry, and production of paragraph passages following surgery. CONCLUSIONS: Our study describes a novel surgical treatment for children with 22q11.2 deletion syndrome with significant velopharyngeal insufficiency (VPI). The procedure wherein is characterized by an extensive mobilization of the carotid artery followed by implantation of a pharyngeal flap. This technique resulted in no significant intra-operative bleeding, and was measured to be successful as noted by nasometry scores and changes in pre- and post-op VELO scores.

Short-term swallowing outcomes following type 1 laryngeal cleft injection.

INTRODUCTION: Interarytenoid injection augmentation at the time of initial diagnostic endoscopy for aspiration and dysphagia may result in near-immediate improvement in swallowing function, potentially obviating the need for future formal endoscopic repair of type 1 laryngeal cleft. Interarytenoid injection augmentation may also address physiologic aspiration. Early treatment of type 1 laryngeal cleft may allow for expedited liberalization of feedings. The objective of this study was to evaluate the effect of interarytenoid injection augmentation (IIA) for type 1 laryngeal clefts (LC-1) on short-term swallowing function assessed by videofluoroscopic swallowing study (VFSS). METHODS: This was a retrospective cohort study of patients age ≤24 months with dysphagia on preoperative VFSS who underwent IIA with calcium hydroxyapatite for LC-1 during direct laryngoscopy and bronchoscopy from June to October 2017 at a tertiary care academic subspecialty hospital. Exclusion criteria included prior endoscopic or open LC repair (n = 1), gastrostomy tube dependence (n = 1), additional procedures at the time of IIA (supraglottoplasty, frenulectomy, n = 1). Children without postoperative VFSS within 30 days of injection were excluded (n = 2). Fifteen children met inclusion criteria for analysis. The primary endpoint was improvement in safely swallowed consistency as defined by recommendation to liberalize diet by at least a half-consistency (e.g. half-honey to nectar thick liquid). Secondary endpoints included clinical assessment of dysphagia and postoperative respiratory events. RESULTS: Median [range] age at injection was 15.2 [7.7-24.3] months and 67% of patients were female (n = 10). The majority (13/15) of patients were full-term and 80% of patients (n = 12) had documented gastroesophageal reflux disease (GERD). Median time from injection to VFSS was 16 [9-29] days. Improvement in safely swallowed consistency was noted in 60% (n = 9) of patients. Aspiration completely resolved in two patients. Swallow function was unchanged in 40% of patients (n = 6); no patients experienced worsening dysphagia. No respiratory complications were documented during inpatient observation. CONCLUSION: IIA is a safe procedure that may result in immediate improvement in dysphagia in select patients with LC-1. IIA does not address neurologic, developmental, or other anatomic etiologies of dysphagia. Additional studies are required to determine long-term efficacy of IIA on dysphagia and pulmonary complications, as well as the patient- and caregiver-related outcome measures.

The diagnostic role of triple endoscopy in pediatric patients with chronic cough.

OBJECTIVE/HYPOTHESIS: Multi-disciplinary aero-digestive centers provide high quality health care through improved outcomes and treatment costs over separate sub specialty clinics. These outcomes are often the result of a common investigative tool known as triple endoscopy: a rigid bronchoscopy performed by an otolaryngologist, flexible bronchoscopy and lavage obtained by a pulmonologist, and an endoscopy with guided biopsies performed by a gastroenterologist. Combining such procedures into one 'triple endoscopy' allows for diagnoses which otherwise might have been missed with just one procedure. The goal of our study was to describe the efficacy of the triple endoscopy procedure in diagnosing recalcitrant aero-digestive conditions, specifically chronic cough. STUDY DESIGN: Retrospective chart review METHODS: Multiple charts from children who underwent the triple endoscopy for chronic cough were retrospectively reviewed from 2005 and 2017. Complete data from the triple procedure was gathered on 243 patients, including findings by sub specialty (otolaryngology, pulmonology, and gastroenterology). RESULTS: Of the 243 patients with complete data who underwent triple endoscopy, 203 (83.5%) children had at least one positive finding. Of these children, 101 (41.5%) had one specialty specific diagnosis, and 102 (42%) had multiple cross specialty diagnoses. When describing the diagnoses, 63 children had gastro esophageal reflux (GER), 14 had eosinophilic esophagitis (EoE), 118 had tracheomalacia, 54 had laryngeal clefts, and 102 children had positive bronchoalveolar lavages. Outcome data was available on 226 patients (93%), of these patients, 188 patients had a diagnosis from the triple scope. Of those patients with a diagnosis and outcome data, 144 (76.6%) children had an improved outcome as a result of a treatment plan targeting that diagnosis, while 16 of the 37 patients without a diagnosis improved. This difference was significant by chi square analysis (p<0.0001). CONCLUSION: The triple scope procedure is a useful investigative tool for patients with recalcitrant aero-digestive complaints like chronic cough. In particular, triple scope can yield more than one specialty specific diagnosis, normally missed by one procedure. The triple scope also leads to improved parental satisfaction by improved cost and healthcare outcomes.

Assessment of the feeding Swallowing Impact Survey as a quality of life measure in children with laryngeal cleft before and after repair.

OBJECTIVE: To cross-validate the Feeding Swallowing Impact Survey (FSIS), a quality of life instrument, specifically to a subpopulation of children who aspirate due to laryngeal cleft. INTRODUCTION: The FSIS is a recently validated instrument used to describe caregiver quality of life (QOL) in children with aspiration due to various causes. To cross-validate the FSIS specifically to the subpopulation of children who aspirate due to laryngeal cleft, we tested the hypotheses that caregivers would report significant different scores form baseline if their children improved at the one year mark postintervention due to either successful conservative or surgical measures (discriminant validity) and would not report significant differences in their FSIS reporting if there was no change in their child's aspiration at the one year mark post intervention (convergent validity). METHODS: The FSIS was administered to the caregivers of 35 children (19 male, 16 female; age range: 5-79 months) who aspirate secondary to known laryngeal cleft (diagnosed by suspension laryngoscopy and inspection). All children had a baseline VFSS demonstrating aspiration and documenting what feeding plan to follow and caregivers completed the FSIS at this point as well. All children regardless of whether they were treated by conservative or surgical intervention underwent a follow-up VFSS at the one year post-intervention mark and the caregivers completed a FSIS at this time point as well. RESULTS: Among two distinct sub-populations of children who underwent either successful conservative or surgical treatment for their laryngeal cleft and demonstrated improvement at the one year mark (as defined by a VFSS documented decreased need for thickener by at least one consistency or more) and where we hypothesized that FSIS scores would not be significantly different, the caregivers reported no significant differences in FSIS scores cleft repair (mean FSIS scores 2.45 (SD 0.88)/2.1 (SD 0.94); p = 0.28). Moreover, as another test to convergent validity, for children who underwent either unsuccessful conservative treatment (and subsequently went on to need surgery) or who were not successfully surgically treated for their laryngeal cleft and demonstrated no significant improvement at the one year mark (as defined by a VFSS documented decreased need for thickener by at least one consistency or more), the caregivers reported no significant differences in FSIS scores cleft repair (mean FSIS scores 2.8(SD 0.79)/2.5(SD 0.88); p = 0.69). For divergent validity, two distinct sub-populations of children who underwent either successful or not successful surgical treatment for their laryngeal cleft (demonstrated by either improvement or lack of improvement at the one year mark VFSS as defined by a decreased need for thickener by at least one consistency or more) revealed significant differences in caregiver FSIS scores cleft repair (mean FSIS scores 1.38 (SD 0.32); 32.8 (SD 0.79); p=<0.0002). DISCUSSION: This results of this study provide convergent and divergent validity supporting the cross-validation of the FSIS instrument to be utilized as a validated QOL instrument to evaluate children with aspiration specifically due laryngeal cleft as another tool with which to evaluate the outcomes of medical or surgical interventions for this disorder.

Time-driven activity-based costing to estimate cost of care at multidisciplinary aerodigestive centers.

OBJECTIVES/HYPOTHESIS: Providing high-value healthcare to patients is increasingly becoming an objective for providers including those at multidisciplinary aerodigestive centers. Measuring value has two components: 1) identify relevant health outcomes and 2) determine relevant treatment costs. Via their inherent structure, multidisciplinary care units consolidate care for complex patients. However, their potential impact on decreasing healthcare costs is less clear. The goal of this study was to estimate the potential cost savings of treating patients with laryngeal clefts at multidisciplinary aerodigestive centers. STUDY DESIGN: Retrospective chart review. METHODS: Time-driven activity-based costing was used to estimate the cost of care for patients with laryngeal cleft seen between 2008 and 2013 at the Massachusetts Eye and Ear Infirmary Pediatric Aerodigestive Center. Retrospective chart review was performed to identify clinic utilization by patients as well as patient diet outcomes after treatment. Patients were stratified into neurologically complex and neurologically noncomplex groups. RESULTS: The cost of care for patients requiring surgical intervention was five and three times as expensive of the cost of care for patients not requiring surgery for neurologically noncomplex and complex patients, respectively. Following treatment, 50% and 55% of complex and noncomplex patients returned to normal diet, whereas 83% and 87% of patients experienced improved diets, respectively. Additionally, multidisciplinary team-based care for children with laryngeal clefts potentially achieves 20% to 40% cost savings. CONCLUSIONS: These findings demonstrate how time-driven activity-based costing can be used to estimate and compare patient costs in multidisciplinary aerodigestive centers. LEVEL OF EVIDENCE: 2c. Laryngoscope, 127:2152-2158, 2017.

Radiation exposure from videofluoroscopic swallow studies in children with a type 1 laryngeal cleft and pharyngeal dysphagia: A retrospective review.

INTRODUCTION: Radiation exposure is recognized as having long term consequences, resulting in increased risks over the lifetime. Children, in particular, have a projected lifetime risk of cancer, which should be reduced if within our capacity. The objective of this study is to quantify the amount of ionizing radiation in care for children being treated for aspiration secondary to a type 1 laryngeal cleft. With this baseline data, strategies can be developed to create best practice pathways to maintain quality of care while minimizing radiation exposure. METHODS: Retrospective review of 78 children seen in a tertiary pediatric aerodigestive center over a 5 year period from 2008 to 2013 for management of a type 1 laryngeal cleft. The number of videofluoroscopic swallow studies (VFSS) per child was quantified, as was the mean effective dose of radiation exposure. The 78 children reviewed were of mean age 19.9 mo (range 4 mo-12 years). All children were evaluated at the aerodigestive center with clinical symptomatology and subsequent diagnosis of a type 1 laryngeal cleft. Aspiration was assessed via VFSS and exposure data collected. Imaging exams where dose parameters were not available were excluded. RESULTS: The mean number of VFSS each child received during the total course of treatment was 3.24 studies (range 1-10). The average effective radiation dose per pediatric VFSS was 0.16 mSv (range: 0.03 mSv-0.59 mSv) per study. Clinical significance was determined by comparison to a pediatric CXR. At our facility a CXR yields an effective radiation dose of 0.017 mSv. Therefore, a patient receives an equivalent total of 30.6 CXR over the course of management. CONCLUSIONS: Radiation exposure has known detrimental effects particularly in pediatric patients. The total ionizing radiation from VFSS exams over the course of management of aspiration has heretofore not been reported in peer reviewed literature. With this study's data in mind, future developments are indicated to create innovative clinical pathways and limit radiation exposure.

Chiari malformations: An important cause of pediatric aspiration.

Chronic aspiration poses a major health risk to the pediatric population. We describe four cases in which work up for chronic aspiration with a brain MRI revealed a Chiari I malformation, a poorly described etiology of pediatric aspiration. All patients had at least one non-specific neurologic symptom but had swallow studies more characteristic of an anatomic than a neurologic etiology. Patients were referred to neurosurgery and underwent posterior fossa decompression with symptom improvement. A high index of suspicion for Chiari malformation should be maintained when the standard work up for aspiration is non-diagnostic, particularly when non-specific neurologic symptoms are present.

Modified Best-Practice Algorithm to Reduce the Number of Postoperative Videofluoroscopic Swallow Studies in Patients With Type 1 Laryngeal Cleft Repair.

IMPORTANCE: There is no consensus as to the timing of videofluoroscopic swallow studies (VFSSs) in determining resolving aspiration after laryngeal cleft repair. There is a growing literature on the effect of radiation exposure in children. OBJECTIVE: To modify a previously published best-practice algorithm based on a literature review and our clinical experience to maintain the quality of care provided after successful type 1 laryngeal cleft repair, while reducing the total number of postoperative VFSSs by 10% or greater. DESIGN, SETTING, AND PARTICIPANTS: The previously published algorithm was modified by a multidisciplinary group at a tertiary care academic medical center (Massachusetts Eye and Ear) and was prospectively applied to 31 children who underwent type 1 laryngeal cleft repair from January 1, 2013, to February 28, 2015. MAIN OUTCOMES AND MEASURES: The number of VFSSs obtained in the first 7 months after surgery was compared with the peer-reviewed literature and with a retrospective cohort of 27 patients who underwent type 1 laryngeal cleft repair from January 1, 2008, to December 31, 2012. RESULTS: The study cohort comprised 31 patients. Their ages ranged from 10 to 48 months, with a mean (SD) age of 23.94 (9.93) months, and 19% (6 of 31) were female. The mean (SD) number of postoperative VFSSs per patient before and after implementation of the algorithm was 1.22 (0.42) and 1.03 (0.55), respectively. The use of the algorithm reduced the number of VFSSs by 0.19 (95% CI, -0.07 to 0.45). This reduction in radiation exposure is equivalent to 1.47 chest radiographs per child per course of care. Surgical success was 87% (27 of 31) compared with our group's previously published success rate of 78% (21 of 27) (absolute difference, 0.09; 95% CI, -0.17 to 0.34). CONCLUSIONS AND RELEVANCE: This modified algorithm to help guide decisions on when and how often to obtain VFSSs after type 1 laryngeal cleft repair can limit patients' radiation exposure, while maintaining high surgical success rates.

Stress velopharyngeal incompetence: Two case reports and options for diagnosis and management.

Stress velopharyngeal incompetence (SVPI) commonly affects brass and wind musicians. We present a series of two patients who presented with nasal air emission following prolonged woodwind instrument practice. Neither patient demonstrated audible nasal air emission during speech, but endoscopy revealed localized air escape/bubbling from different sites for each patient with instrument playing only. Both underwent tailored surgical treatment with resolution of symptoms during performance. Diagnosis of SVPI requires examination during the action that induces VPI to allow for directed management. Treatment should be targeted based on nasopharyngoscopy findings.

Nasometry, videofluoroscopy, and the speech pathologist's evaluation and treatment.

The speech-language pathologist (SLP) plays an important role in the assessment and management of children with velopharyngeal insufficiency (VPI). The SLP assesses speech sound production and oral nasal resonance and identifies the characteristics of nasal air emission to guide the clinical and surgical management of VPI. Clinical resonance evaluations typically include an oral motor exam, identification of nasal air emission, and analysis of the speech sound repertoire. Additional elements include perceptual assessment of intra-oral air pressure, the degree of hypernasality, and vocal loudness/quality. Clinical speech and resonance evaluations are typically the gold-standard evaluation method until a child reaches 3-4 years of age, when sufficient compliance levels and speech-language abilities allow for participation in instrumental testing. At that time, objective assessment measures are introduced, including nasometry, videofluoroscopy, and/or nasopharyngoscopy. Nasometry is a computer-based tool that quantifies nasal air escape and allows comparison of the score against normative data. Videofluoroscopy is a radiographic tool used to assess the shaping of the velum and closure of the velopharyngeal mechanism during speech production. Evaluation findings guide decision making regarding surgical candidacy and/or the therapeutic management of VPI. Surgery should always be pursued first when an anatomic deficit prevents velopharyngeal closure. Therapy should always be pursued in children who present with velopharyngeal mislearning and/or motor planning issues resulting in VPI. It is not uncommon for children to receive a combination of surgical intervention and speech resonance therapy during their VPI management course. Collaborative decision making between the otorhinolaryngologist and the SLP provides optimal patient care.