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 3 Feeding therapy.

Regarding feeding therapy as an initial management strategy

Percentage of members

Healthy patients

All patients with type I LTEC

40% (8/20) 60% (12/20)

All patients without respiratory compromise and/or failure to thrive

Do not use feeding therapy All patients with type I LTEC

0%

45% (9/20) 35% (7/20) 20% (4/20)

High risk patients

All patients without respiratory compromise and/or failure to thrive

Do not use feeding therapy

interarytenoid fi ller injection include its reversibility, short pro- cedure time, and evaluation of the potential effect of a de fi nitive repair. The potential risks of injection include fi ller migration into the subglottis, untoward fi brotic scarring of the injected regions, and need for repeat procedure [11 e 14] . In assessing patient candidacy for surgery, the majority of members (65%, 13/20) did not use minimum weight as a criterion for endoscopic type I laryngeal cleft repair. The preferred method of ventilating the patient during repair was spontaneous respiration (95%, 19/20), with 5% (1/20) favoring intubation with a small endotracheal tube [15] . No consensus was achieved regarding the use of antibiotic prophylaxis and pre-operative corticosteroids. Routine antibiotic prophylaxis is used by a minority of the members (40%, 8/20). A pre-operative dose of systemic corticosteroids at an airway dose (intravenous dexamethasone 0.25 e 0.5 mg/kg) was used by 55% (11/20) of members. Of those who offer interarytenoid augmentation, the choice of fi ller agent was largely surgeon-dependent. Several options include calcium hydroxyapatite, carboxymethylcellulose, hyaluronic acid, absorbable gelatin sponge (Gelfoam), and autologous fat ( Table 4 ). Endoscopic surgical closure of a type I LTEC is achieved by denuding the interarytenoid mucosa and re-approximating this area with sutures. This can be performed using a laser, cold in- struments, or a combination; the choice of instrument is largely surgeon-dependent ( Table 4 ). Regarding suture type, all members utilize absorbable sutures in the closure of the LTEC, speci fi cally polyglactin 910 or polydiaxone ( Table 4 ). Suture size ranged from 4 to 0 to 7-0, and was dependent on the size of the patient. Single layered closure (to encompass the anterior and the posterior mucosal approximation) is preferred by 70% (14/20) of members. 6.6. Section 3.2: intra-operative considerations

Routine division of the aryepiglottic folds and suturing of the cor- niculate cartilages were each performed by just under half of the members (9/20 ¼ 45% and 8/20 ¼ 40%, respectively).

6.7. Section 3.3 post-operative management and follow-up

Again, there was individual practice variability in the post- operative management following endoscopic type I LTEC repair. Post-operative course of antibiotics was favored by a minority (40%, 8/20) of members. Fifty percent of members (10/20) did not routinely prescribe a course of post-operative systemic corticoste- roids following endoscopic type I LTEC repair. Endoscopic type I laryngeal cleft repair is performed as an inpatient procedure. The degree of post-operative monitoring, though, was variable and likely based on institution-speci fi c resource availability: 35% (7/20) admit to an intensive care unit, 40% (8/20) admit to a monitored fl oor bed, and 25% (5/20) admit to a step-down unit. The duration of inpatient monitoring was vari- able, and ranged from 1 to 3 nights [16] . Regarding post-operative diet, 50% (10/20) members favor im- mediate clinical feeding assessment and dietary advancement. Forty- fi ve percent of members (9/20) favor resuming the pre- operative diet, until a subsequent swallowing evaluation (MBS or FEES). No other post-operative restrictions (i.e. voice rest) are generally recommended. The timing of the fi rst post-operative follow-up ranged from 1 to 6 weeks. Forty- fi ve percent (9/20) perform routine post-operative swallowing assessment (either MBS or FEES) at 4 e 8 weeks after intervention. Thirty percent (6/20) favor serial clinical evaluation without formal swallowing assessment (MBS or FEES). It is important to note that all patients that demonstrated silent aspi- ration prior to surgical intervention should undergo MBS and/or FEES [17] . Twenty- fi ve percent of members (5/20) will only perform post-operative MBS and/or FEES if this is the case.

Table 4 Operative considerations.

Question

Percentage of members

Offer interarytenoid fi ller injection

Yes

40% (8/20) 60% (12/20) 33.3% (5/15) 13.3% (2/15) 20% (3/15) 13.3% (2/15) 6.7% (1/15) 13.3 (2/15) 40% (8/20) 30% (6/20) 5% (1/20) 25% (5/20) 60% (12/20) 40% (8/20) 40% (8/20) 60% (12/20) 45% (9/20) 55% (11/20)

No

Ideal fi ller agent

No ideal agent

Carboxymethylcellulose Calcium hydroxyapatite

Fat

Gelfoam

Hyaluronic acid

Method for denuding the interarytenoid mucosa

Carbon dioxide laser

Cold dissection Thulium laser

Combination of ‘ hot ’ and ‘ cold ’ instruments

Suture type

Polyglactin 910 (Vicryl)

Polydiaxone (PDS)

Routinely suture the corniculate cartilages

Yes

No

Routinely divide the aryepiglottic folds

Yes

No

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