Cofer, Shelagh A.

Key Clinical MessageLaryngoscopy is the gold standard to diagnose exercise‐induced laryngeal obstruction, though inspiratory flow‐volume loop may provide a clue. We combined tidal flow‐volume loop analysis plus laryngoscopy during exercise and found that cigar‐shaped – not flattened – inspiratory loops are associated with obstruction. Pursed‐lip breathing slows inhalation thereby reducing vocal fold adduction.

AbstractAimPersistent or recurrent wheezing is a common indication for flexible bronchoscopy, as anatomic and infectious or inflammatory changes are highly prevalent. We sought to evaluate the prevalence of anatomic, infectious, and inflammatory disease in a cohort of children undergoing flexible bronchoscopy for wheezing or poorly controlled asthma.MethodsWe retrospectively reviewed all children <18 years old who underwent flexible bronchoscopy at our center from October 29, 2012‐December 31, 2016 for the primary or secondary indication of wheezing (persistent, frequently recurring, or atypical) or poorly controlled asthma.ResultsA total of 101 procedures were identified in 94 patients, aged 3 months to 18 years. Potential anatomic causes for wheezing identified in 45.7% of patients and inflammatory changes in 49.5% of procedures. This included the identification of a laryngeal cleft in 17% for which half required medical or surgical management. Tracheobronchomalacia was the most commonly identified anatomic lesion. Thirty children from this cohort had poorly controlled asthma. Among this subgroup, 54% had increased neutrophils on BAL and 30% had an anatomic contributor to wheezing, including one with a laryngeal cleft. Based on findings from flexible bronchoscopy, management changes made in 63.8% of patients. This included medication changes in 54 and surgical intervention in 9.DiscussionWe conclude that transnasal flexible bronchoscopy has high yield in children with recurrent, persistent, or atypical wheezing and those with poorly controlled asthma. Laryngeal cleft has a reasonably high prevalence that warrants specific evaluation in this population.

Insertion of tympanostomy tubes is a common elective pediatric surgical procedure and is typically performed under general anesthesia. The potential to reduce general anesthetic requirements for young children has led to increased interest in alternatives for tympanostomy tube placement. A tympanostomy tube system, developed to enable tympanostomy tube placement in a single pass on conscious patients under moderate sedation, was evaluated. A prospective study on 128 children and 253 tympanostomy tube placements conducted at 4 centers in the United States demonstrated an 88.3% success rate in performing the procedure under moderate sedation with adverse events within normal rates reported in the literature. The feasibility of completing tympanostomy tube placement under moderate sedation enables avoidance of general anesthesia and provides additional choices to physicians and parents.

Split cord malformation (SCM) is a rare abnormality of notochord development. The majority of cases occur in the thoracolumbar region, with more than 30 cases of cervical SCM reported. The clinical impact of SCMs involving the cervical cord is therefore largely unknown. In addition, the concomitant finding of brainstem involvement is presumably incompatible with life in the majority of patients, resulting in a paucity of data regarding this clinical scenario. In this paper the authors present the first case, to their knowledge, of an incomplete cervical SCM involving the brainstem and discuss its clinical impact, diagnosis, and management.

Objectives/HypothesisTo evaluate the effectiveness, durability, and safety of a tissue filler (dextranomer and hyaluronic acid copolymer) when injected submucosally in the nasopharynx to treat velopharyngeal insufficiency (VPI) in pediatric patients.Study DesignRetrospective case series.MethodsCharts were reviewed for all patients treated with injectable filler at a tertiary children's center for VPI from April 2010 through September 2013. Main outcome measures included perceptual speech assessments before and after the procedure, velopharyngeal gap size on nasendoscopy, and nasalance. Length of follow‐up, length of surgery, hospital admission, and complications were also identified.ResultsAfter injection augmentation pharyngoplasty, 93% of patients had no or mild hypernasality, 83% had resolution of nasal grimace, and 96% had resolution of audible nasal emission. Complications were minor and included mucosal infection, neck pain, snoring, and obstructive sleep apnea.ConclusionsUse of injectable filler to augment the nasopharynx is an effective, minimally invasive therapy for small or moderate‐sized velopharyngeal gaps, with shorter procedural times, easier recovery, and acceptable durability.Level of Evidence4 Laryngoscope, 126:S5–S13, 2016

SummaryHaemorrhagic complications remain a challenge with surgical procedures in patients with bleeding disorders. In children and young adults, the most commonly performed surgeries are tonsillectomies and/or adenoidectomies. Adequate haemostasis in these patients with bleeding disorders is centred on comprehensive perioperative haemostatic support and dexterous surgical technique. The aim of this study was to assess postoperative bleeding complications with tonsillectomy and/or adenoidectomy in children and young adults with known bleeding disorders. Retrospective review of all patients aged <25 years with known bleeding disorders who underwent tonsillectomy and/or adenoidectomy at Mayo Clinic, Rochester MN between July 1992 and July 2012. In contrast to reported literature, we observed a higher rate of bleeding complications (10/19, 53%) despite aggressive haemostatic support and appropriate surgical techniques. Delayed bleeding (>24 h postoperatively) was more common than early bleeding; and recurrent bleeding was associated with older age. Children and young adults with haemorrhagic diatheses undergoing adenotonsillectomy are at a higher risk of delayed bleeding and require close monitoring with haemostatic support for a prolonged duration in the postoperative period. A uniform approach is needed to manage these patients perioperatively by establishing standard practice guidelines and ultimately reduce postsurgical bleeding complications.

Objective This study explored posterior nasopharyngeal augmentation with an acellular dermal matrix sheeting. Design Evaluation of the persistence and safety of a submucosal implant of rolled acellular dermis over a 3-month period in a piglet model. Setting Institute Hills Facility, part of the Mayo Clinic Rochester health care facility. Participants Fifteen 5-week-old domestic piglets of unspecified gender. Interventions Twelve piglets were implanted at age 5 weeks with a rolled sheet of acellular dermal matrix (Strattice). Implants were inserted in a submucosal pocket in the soft palate. Three piglets underwent sham operations, with creation of submucosal pockets without implantation. After a 3-month observation period, the palates were harvested for evaluation. Results Grossly, persistence of bulk at the surgical site in 5 of the 12 implanted piglets was noted at 3 months. Histologically, no persistence of the dermal matrix could be observed. Incorporation and/or resorption of the dermal matrix occurred with minimal to no host inflammatory response. Conclusion This experiment demonstrated the safety of a rolled acellular dermal implant in a submucosal location in a pig model, without surgical complication, host inflammatory reaction, or rejection. Minimal, if any, bulk of the implant persisted in the implanted location after 3 months. Although acellular dermal matrix sheeting appears to be safe and well-tolerated, it does not offer a long-term treatment option for posterior pharyngeal augmentation.