Cohen, Aliza P.

Objectives/HypothesisDescribe the preoperative evaluation of patients with glottic diastasis who are candidates for endoscopic posterior cricoid reduction (EPCR) and their perioperative and postoperative surgical and voice outcomes, and validate the aerodynamic benefit of EPCR using computation fluid dynamics (CFD)‐based modeling from computed tomography (CT) scans.Study DesignRetrospective case series.MethodsThirteen patients who underwent EPCR were followed from 2013 to 2017. They received a preoperative voice evaluation, microlaryngoscopy and bronchoscopy, dynamic voice CT (performed on patients seen from 2014 to study completion), and postoperative voice evaluation (n = 12). Postoperative inpatient days, complications, and postoperative endoscopic intervention were collected. To validate the aerodynamic benefit of EPCR, CFD modeling was carried out on one patient.ResultsThirteen patients (nine females, nine with intubation injury, and four with post–airway reconstruction dysphonia) underwent EPCR at a mean age of 11.0 years. The mean preoperative and postoperative Pediatric Voice handicap Index scores were 53.8 and 33.8, respectively (P = .006). Mean maximum phonation time preoperatively and postoperatively was 5.3 and 6.7, respectively (P = .04). Of eight patients who underwent preoperative CT imaging, all demonstrated a posterior gap. Modeling demonstrated a change in flow and pressure. The mean hospital stay was 2.4 days. Nine patients underwent postoperative endoscopic intervention, and one experienced a complication that resolved with intervention.ConclusionsPatients who underwent EPCR for dysphonia following intubation or airway reconstruction showed improvements in vocal efficiency, loudness, and perceived voice handicapping. Their hospital stay was brief, with few complications. CFD modeling corroborated these clinical findings. EPCR thus warrants consideration in the management of patients with posterior glottic diastasis.Level of Evidence4 Laryngoscope, 129:S1–S9, 2019

Abstract Rationale We previously demonstrated that children with obstructive sleep apnea have increased blood pressure associated with changes in left ventricular mass index. Others have shown in adults that blood pressure variability is an important predictor of changes in left ventricular mass. The baroreflex system buffers blood pressure changes by varying heart rate. We have thus hypothesized that (1) baroreflex system gain is increased during sleep, improving blood pressure buffering; (2) children with obstructive sleep apnea lack this baroreflex gain increase; and (3) reduced blood pressure buffering results in exaggerated blood pressure variability that is associated with end-organ damage. Objectives Compare measures of left ventricular mass index and nighttime baroreflex gain of healthy children to those of children with obstructive sleep apnea. Methods A total of 169 children (50 control subjects, 63 with mild obstructive sleep apnea, and 56 with severe obstructive sleep apnea) with a mean age of 9.9 years (±2.2) underwent echocardiography followed by polysomnography with continuous blood pressure measurement. Baroreflex gain was calculated in time and frequency domains. Measurements and Main Results Healthy children demonstrated a nighttime pattern of increasing baroreflex gain. Children with obstructive sleep apnea had decreased nighttime baroreflex gain compared with control subjects. Nighttime blood pressure and blood pressure variability were significantly correlated with left ventricular mass index. Conclusions Obstructive sleep apnea is associated with a decrease in nighttime baroreflex gain and an increase in blood pressure variability. This increase is correlated with changes in left ventricular mass index.

Abstract Rationale An association between neurocognitive deficits and pediatric sleep-disordered breathing has been suggested; however, weak correlations between disease severity and functional outcomes underscore the lack of knowledge regarding factors modulating cognitive morbidity of sleep-disordered breathing. Objectives To identify the parameters affected by sleep-disordered breathing that modulate cerebral oxygenation, an important determinant of cognition. A further objective was to use these parameters with demographic data to develop a predictive statistical model of pediatric cerebral oxygenation. Methods Ninety-two children (14 control subjects, 32 with primary snoring, and 46 with obstructive sleep apnea) underwent polysomnography with continuous monitoring of cerebral oxygenation and blood pressure. Analysis of covariance was used to relate the blood pressure, sleep diagnostic parameters, and demographic characteristics to regional cerebral oxygenation. Measurements and Main Results To account for anatomic variability, an index of cerebral oxygenation during sleep was derived by referencing the measurement obtained during sleep to that obtained during wakefulness. In a repeated measures model predicting the index of cerebral oxygenation, mean arterial pressure, rapid eye movement (REM) sleep, female sex, age, and oxygen saturation had a positive effect on cerebral oxygenation levels, whereas arousal index and non-REM (NREM) sleep had a negative effect. Conclusions Increasing mean arterial pressure, age, oxygen saturation, and REM sleep augment cerebral oxygenation, while sleep-disordered breathing, male sex, arousal index, and NREM sleep diminish it. The proposed model may explain the sources of variability in cognitive function of children with sleep-disordered breathing.