Type 1 Laryngeal Cleft Repair

[Dr. Hamdy El-Hakim]
Clinical examination, on its own, is never enough, and that is an established benchmark of practice. Then we meet together in the aspiration clinic, no less than half an hour consultation, going through a standard set of questions and elimination of risk factors, inquiry about cardiac, respiratory, developmental, the rest of it. If we can get away after the FEES by introducing a thickened diet, a modified diet, or some advice in terms of pacing and so forth, then that's good, we're going to re-evaluate back again and see how does the child do.

That includes preliminary assessment and treatment sometimes of gastric esophageal reflux disease, bearing in mind that our glorious PPIs are now uncovering their ugly face in terms of side effects and so forth. The next step, I never really stage endoscopy and surgery. If I am failing with conservative or medical treatment, I will go and scope. I will never delay an endoscopy if the child has already dangerous symptoms like blue spells or apparent life-threatening episodes, or they failed within a short period of time if you were getting recurrent pneumonias and chest infections, or if they have an alternate route of feeding.

Because one of the main objectives of any clinic or any program is to reduce and shorten as much as possible the period of non-oral feeding. Then I will go and tell the parents, depending on my findings, "Look, I've seen a mobility disorder, I'll see what I can do on the day, of reasons." Or, "I am suspecting that we have a posterior problem over here, and I need to augment that area." I give them an overall view of the two main methods, whether it's a surgical repair or an injection. I quite often will say, "There is a possibility of a GI specialist coming in the same time."

I quite often will take bronchoalveolar lavage as well in the same time. The jury are out in terms of the utility of the yield, whether you really depend on the identification of lipid-laden macrophages or not, whether you have a child who has oropharyngeal flora and way more than contamination in the lower airway. Trust me, the interpretation of this in the literature and experience is at least heterogeneous. At the end of the day, I try and limit trips. I try and combine the endoscopic examination. I will do the airway examination to start with first with agreement with the respirologist. In follow-ups, should the child have adequate examination and treatment by otolaryngology and the remainder is a substantial plan for respriology, then they go and do subsequent lower airway examination. That, in my opinion, is more economical in terms of time, effort, and grouping of people together.

[Dr. Gopi Shah]
Yes, every once in a while I'll have a young newborn that's admitted within the first three to six weeks of life with, a blue spell. They get admitted. It's noted that they're having feeding difficulties. They see speech and have a feeding evaluation and, there's a concern for aspiration. We get consulted on the inpatient side and then NICU usually. If we're not making progress, we don't have a good feeding plan, then we end up doing these DLB evaluations while they're inpatient. At that time, do you usually also go ahead and talk to your GI colleagues if you are planning a DLB? It makes sense to me on the outpatient side, with a structured aspiration and feeding clinic because that partnership and that system is set up for it. Every once in a while, the consult is outside of that system.

[Dr. Hamdy El-Hakim]
No, it makes sense. Most definitely. Particularly the age range that you're talking about, Gopi, is tricky because you don't have enough history to tell whether the child has esophageal problems. There are some that will do. I remember a CMV-infected child, congenital CMV child, who basically had raging reflux and that was one of the very few slam-dunk situations where a fundo has made a world of difference without any problem. That is the other factor that you occasionally may see on a VFSS. You don't see an oropharyngeal abnormality, meaning aspiration from above, but an aspiration from below with regurgitation of the bolus and entry in the airway.

[Dr. Gopi Shah]
Then what is part of your postoperative management? Are these patients on PPIs? Do you send them home with a steroid taper, or a modified diet, or anything like that?

[Dr. Hamdy El-Hakim]
The diet depends on the result of the FEES, and it doesn't get changed immediately. Postoperatively, if they are on PPIs, they will continue on PPIs. I make sure that if the child has had pneumonias and wheezing, that they basically have been, let's call it, cleaned enough. Some bronchodilators and inhaled steroids are given beforehand, and they continue afterwards, and that varies, that gets individualized.

If they have not been on PPIs before, I only give them two weeks' worth of it. This is a tiny wound at the end of the day. your tonsillectomy heals completely after two weeks. That will probably heal in a handful of days. I don't really give a whole host of instructions to the parents. What is what you get in the immediate postoperative period? I never really repeat the assessment before eight to ten weeks. I used to try and be over-optimistic, and I think most surgeons actually have confirmed that. At 8 to 10 weeks, they come back and see you. What happens in your clinic? How do you assess them? What's a good outcome? What outcomes are you looking at? What's your metrics?

[Dr. Hamdy El-Hakim]
Good question. I tell the guys in training that I am autistic about how I assess and how I do it back again. I have a drill of questions. It's a smart phrase that I put in our electronic medical record system, and there is an equivalent ask for all when they come back, in addition to asking whether they had problems afterwards, including pain, readmission, and so forth.

We basically go and say, okay, how do you feel right now? If the child is still on a modified diet, then we really need to thin that during the examination and repeat the FEES or the modified period as well. If the child is on a non-modified diet, sometimes the parents would come and say the choking has gone down and so forth. I would caution, I always went along with, or initially, I went along with what the parents have seen, because at the end of the day, you don't treat a test, you treat the child.

I must admit that the resolution sometimes of the symptoms precedes the resolution of the instrumentals. One has to be skeptic also about the placebo effect. Parents are always hopeful that something is going to happen, child is going to be better. It also depends on the season. You might be doing it in the summer or the spring and the winter has gone, the number of infections are less. By the same token, they might have been ill because you've done it in the beginning of the fall and they have siblings and they've had a few colds and there is an interpretation that it's a doom and gloom.

8 to 10 weeks, I'll say that, and again, I need to remeasure that, it's probably, a response related to your surgery directly within the first six months in most of your successful patients. You get rid of the thickening or you thin it even more, or you work towards a thinner consistency, water type of consistency. The question that you pose is also very important.

If I have a neurologically affected child, and I'm very precise about what's a neurologically affected child, because there are neurologically affected children that their neurologic problem doesn't have anything to do with dysphagia. There's no need for lumping that, but you want as much as possible an oral component to those children. You need to start working it so that the plasticity of the brain doesn't actually get lost in terms of swallowing function.