September 2019 HSC Section 1 Congenital and Pediatric Problems

J.C. Yeung et al. / International Journal of Pediatric Otorhinolaryngology 101 (2017) 51 e 56

Table 1 Diagnostic considerations.

Question

Percentage of members 85% (17/20) 15% (3/20) 75% (15/20) 25% (5/20) 60% (12/20) 30% (6/20) 10% (2/20) 55% (11/20) 5% (1/20) 30% (6/20) 10% (2/20) 50% (10/20) 50% (10/20) 65% (13/20) 15% (3/20) 15% (3/20)

FFL

Performed in all patients presenting with dysphagia and aspiration

Performed in patients whose clinical presentation is suggestive of laryngeal pathology (i.e. presence of stridor, hoarse voice, etc.)

MBS

Performed in all patients presenting with dysphagia and aspiration

Performed in high risk patients only

FEES

Performed in all patients presenting with dysphagia and aspiration

Performed in high risk patients only

Not a pertinent investigation

CXR

Performed in all patients presenting with dysphagia and aspiration

Performed in high risk patients only

Performed in patients whose clinical presentation is suggestive of pulmonary sequelae

Not a pertinent investigation

DLB

Performed in all patients presenting with dysphagia and aspiration

Performed in high risk patients only

Patients with type I LTEC in addition to another midline anomaly

Workup for associated syndromes a

Patients with type I LTEC and high risk features All patients with newly identi fi ed type I LTEC

No routine work up 5% (1/20) FFL - Flexible fi ber-optic laryngoscopy, MBS e Modi fi ed barium swallow, FEES e fi ber-optic endoscopic evaluation of swallowing, CXR e chest X-ray, DLB e direct laryn- goscopy and bronchoscopy.

The bold/italicized responses are the ones that had the highest response rate on the survey. a Syndromes associated with laryngeal cleft include: VACTERL, Pallister-Hall, Opitz G.

Table 2 Consultation.

Referral

Percentage of members

75% (15/20) 25% (5/20)

Feeding team/Speech language therapy

All patients with dysphagia/aspiration

Selective referral based on risk factors and clinical presentation

Only after type I LTEC is identi fi ed

0% 0%

Do not generally refer

Gastroenterology

All patients with dysphagia/aspiration

5% (1/20)

95% (19/20)

Selective referral based on risk factors and clinical presentation

Only after type I LTEC is identi fi ed

0% 0%

Do not generally refer

Pulmonology

All patients with dysphagia/aspiration

5% (1/20)

90% (18/20)

Selective referral based on risk factors and clinical presentation

Only after type I LTEC is identi fi ed

5% (1/20)

Do not generally refer

0% 0%

Neurology

All patients with dysphagia/aspiration

90% (18/20)

Selective referral based on risk factors and clinical presentation

Only after type I LTEC is identi fi ed

5% (1/20) 5% (1/20)

Do not generally refer

The identi fi cation of a LTEC in conjunction with other midline anomalies should prompt a work-up for associated syndromes, including VACTERL association, Opitz G Syndrome, and Pallister- Hall Syndrome.

members. Average treatment duration was 7 months, with a range of 3 e 12 months. With respect to age of expected resolution, the members acknowledged that there is signi fi cant individual patient variability and no consensus was reached. Indications for pro- ceeding to surgical intervention included lack of clinical improve- ment, recurrence/worsening of respiratory function, and persistence of aspiration on MBS. Other factors that may in fl uence the duration of medical therapy include the degree of dehydration and constipation caused by thickening as well as social/family consequences of prolonged thickening, such as cost and inconve- nience [8,9] .

6.4. Section 2: medical management

Conservative management strategies include the control of concomitant laryngopharyngeal re fl ux as well as feeding therapy and thickening of the diet. Empiric antire fl ux therapy is suggested by 30% (6/20), while the remaining 70% (14/20) recommend anti- re fl ux therapy when symptoms of laryngopharyngeal re fl ux are present [8] . In otherwise healthy patients, all (100%) members considered feeding therapy to be an appropriate initial management, with 60% (14/20) of members recommending feeding therapy in the absence of pulmonary complications and/or failure to thrive. No consensus was achieved regarding patients with higher risk of failure, such as those with a history of prematurity, neuromuscular disorder, ge- netic syndrome, etc. ( Table 3 ). The duration of feeding therapy was variable amongst the

6.5. Section 3.1: pre-operative considerations

The options for surgical intervention include interarytenoid augmentation with injectable fi ller and endoscopic suture repair of the LTEC. It is important to counsel patient families that surgery may not correct the aspiration, as pharyngeal dis-coordination may also contribute to dysphagia and aspiration [4,10] . Forty percent of members (8/20) will conduct a trial of fi ller augmentation, while 60% (12/20) would proceed to de fi nitive repair. The bene fi ts of

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