Tracheal pH monitoring: a pilot study in tracheostomy dependent children.

OBJECTIVES: 1. Determine the feasibility of measuring tracheal pH with a novel non-aqueous probe designed for oropharyngeal pH monitoring. 2. Correlate clinical and subclinical laryngopharyngeal reflux aspiration events with esophageal pH measurements. METHODS: Five children with chronic indwelling tracheostomies undergoing routine endoscopy and pH probe monitoring at a tertiary care pediatric aerodigestive center between October 2007 and January 2008 were identified for this prospective feasibility pilot study. The non-aqueous Restech Dx-pH probe was subsequently affixed to each child's tracheostomy with the probe tip confirmed to be within the tracheal lumen. Esophageal and tracheal probe pH measurements were subsequently recorded until the child was unable to tolerate the study or 24 h elapsed. Tracheal pH tracings were compared directly to esophageal pH tracings. Esophageal biopsy and bronchoalveolar lavage data were reviewed for each child. RESULTS: 3/5 children tolerated the tracheal probe for greater than 18 h. Adequate tracheal pH tracings were demonstrated for all children while the probe was in position. Mean baseline tracheal pH was 7.8. One child demonstrated direct correlation between acidic esophageal reflux events and decreased tracheal pH. Esophageal biopsy confirmed the presence of active inflammation consistent with reflux in this child. CONCLUSION: Tracheal pH can be accurately recorded with the Restech Dx-pH probe. The technology may allow further investigations to determine the impact of gastroesophageal refluxate aspiration and empiric antireflux therapy in children with aerodigestive symptoms.

Podcasting: contemporary patient education.

Portable video technology is a widely available new tool with potential to be used by pediatric otolaryngology practices for patient and family education. Podcasts are media broadcasts that employ this new technology. They can be accessed via the Internet and viewed either on a personal computer or on a handheld device, such as an iPod or an MP3 player. We wished to examine the feasibility of establishing a podcast-hosting Web site. We digitally recorded pediatric otologic procedures in the operating room and saved the digital files to DVDs. We then edited the DVDs at home with video-editing software on a personal computer. Next, spoken narrative was recorded with audio-recording software and combined with the edited video clips. The final products were converted into the M4V file format, and the final versions were uploaded onto our hospital's Web site. We then downloaded the podcasts onto a high-quality portable media player so that we could evaluate their quality. All of the podcasts are now on the hospital Web site, where they can be downloaded by patients and families at no cost. The site includes instructions on how to download the appropriate free software for viewing the podcasts on a portable media player or on a computer. Using this technology for patient education expands the audience and permits portability of information. We conclude that a home computer can be used to inexpensively create informative surgery demonstrations that can be accessed via a Web site and transferred to portable viewing devices with excellent quality.

Injection pharyngoplasty with calcium hydroxyapatite for treatment of velopalatal insufficiency.

OBJECTIVE: To evaluate the efficacy of injectable calcium hydroxylapatite for treatment of velopalatal (VP) insufficiency (VPI). DESIGN: Observational case series of 7 patients treated with injectable calcium hydroxylapatite for VPI and followed for 10 to 24 months. SETTING: Academic pediatric otolaryngology practice. PATIENTS: Seven children aged 6 to 16 years with clinically significant VPI stemming from documented small VP gaps and who did not benefit from speech therapy were treated with calcium hydroxylapatite injection pharyngoplasty. INTERVENTION: Posterior pharyngeal wall augmentation with calcium hydroxylapatite. MAIN OUTCOME MEASURES: Treatment success was defined as (1) speech improvement to the degree that parents felt no additional treatment was needed and (2) meeting postoperative nasometric measures. Treatment failure was defined as parental report of insufficient improvement in speech. Complications and additional treatments for VPI were noted. RESULTS: There were no major complications in any of the 7 children injected with calcium hydroxylapatite. There was 1 minor complication: 1 patient was readmitted for postoperative pain and dehydration. Of the 7 patients, 4 experienced a satisfactory result for up to 17 months. Findings from postoperative nasometry were either within reference range, or less than 1 SD greater than the reference range, for all sounds. There were 3 treatment failures, each with preexisting craniofacial abnormality. Two patients in the group that failed treatment later underwent revision superior pharyngeal flap surgery without complication or hindrance from the calcium hydroxylapatite injection. Four children underwent subsequent magnetic resonance imaging evaluations up to 1 year after injection, which revealed no evidence of migration. CONCLUSIONS: The data from this small series suggest that posterior pharyngeal wall injection with calcium hydroxylapatite is safe and may be effective in treating select patients with VPI. Further longitudinal studies, with a larger series of patients, examining the safety, efficacy, and patient selection are warranted to better understand the possible use of posterior pharyngeal wall injection of calcium hydroxylapatite in children with symptomatic VPI.

Botulinum toxin A: a novel adjunct treatment for debilitating habit cough in children.

Vocal fold injection with botulinum toxin type A (BTX-A) may be used as an adjunct treatment for habit cough in children. We conducted a retrospective review of 3 cases involving children aged 11 to 13 years with habit cough treated with vocal fold injection of BTX-A. Injections of BTX-A to the thyroarytenoid muscles were effective in breaking the cough cycle in all 3 children. Their coughs recurred but were controlled with 4 to 8 sessions of behavioral therapy. Behavioral therapy remains the first-line treatment, but BTX-A may be a useful complement to behavioral therapy in patients who fail standard treatments or in those with severe cough who have limited or delayed access to mental health professionals. This is the first report, to our knowledge, on the use of BTX-A in the treatment of a habit cough.

Vocal fold medialization in children: injection laryngoplasty, thyroplasty, or nerve reinnervation?

OBJECTIVE: To review surgical interventions for pediatric unilateral vocal fold immobility (UVFI). DESIGN: Retrospective medical chart review. SETTING: Two tertiary academic centers. PATIENTS: All children who underwent vocal fold medialization for dysphonia, with or without aspiration, from January 2004 to September 2006. INTERVENTIONS: Injection laryngoplasty, ansa cervicalis-recurrent laryngeal nerve anastomosis, or thyroplasty. MAIN OUTCOME MEASURES: Age, sex, intervention, etiology, time from onset of UVFI to surgery, subjective success in improving voice, subjective duration of improvement, and complications. RESULTS: Twenty-seven procedures were performed in 15 patients (mean age, 10.6 years). Nineteen injection laryngoplasties, 3 thyroplasties (1 bilateral), 2 ansa cervicalis-recurrent laryngeal nerve reinnervation procedures, 1 adduction arytenoidopexy, and 1 cricothyroid joint subluxation were performed. Causes of UVFI included thoracic surgery in 6 cases (40%), prolonged intubation in 4 (26%), central nervous system neoplasm in 3 (20%), unknown etiology in 1 (7%), and anoxic brain injury in 1 (7%). The mean duration from onset of symptoms to treatment was 47 months. There was 1 surgical complication (postoperative aspiration pneumonia following thyroplasty while the patient was under local anesthesia). Parents reported a satisfactory outcome in all cases. CONCLUSIONS: Injection laryngoplasty, thyroplasty, and nerve reinnervation can be performed in pediatric patients with good outcomes and an acceptable safety profile. This article describes the experiences of 2 institutions with phonosurgery for UVFI in children and provides insight into the advantages and disadvantages of each procedure. Prospective studies, with validated quality-of-life measurements, are needed to greater clarify the role of different types of phonosurgery in children with UVFI.