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  • Period of drug administration followed by a resting period after which the cycle starts over again. Chemo dose is calculated based on patient’s height and body weight. Chemo is not only toxic to tumor cells adverse reactions usually affect parts of the body that have a rapid turnover such as blood cells and cells of the GI tract.
  • Define neuropathy: any disease of the nerves Peripheral neuropathy: any syndrome in which muscle weakness, paresthesias, impaired reflexes and autonomic symptoms in the hands and feet common. Autonomic: self controlling, functioning independantly. Relating to the autonomic nervous system: The part of the nervous system that controls involuntary bodily functions. The ANS consists of motor nerves to visceral effectors: smooth muscle, cardiac muscle, glands such as salivary glands, gastric, sweat glands.
  • Parents want child to complete chemo. Cycle and get concerned regarding interruption of chemo regimen and how that affects their treatment. Prolong their chemo cycle. Also parental concerns regarding the need to reduce the strength of the dose and if that too may affect the outcome of the cancer treatment.
  • Range of time it took for swallow function to return to pre- vincristine status was weeks to months. Some patients returned for numerous follow up VFSS in the range of 2- >8 at scheduled intervals to assess for improvement. YES some patients did experience a re-currence of symptoms and documented aspiration once the Vincristine was re-started and we took them through the cycle again of altering diet, MD changed strength/dose of V.
  • Jimmy Fund Clinic at Dana Farber Cancer Institute
  • 7 months into treatments, diagnosed with pna.
  • Discussion held with oncology team and decision made to withhold vincristine 3 weeks later although Vinc. d/c pt. Continues to exhibit signs of neurotoxicity./2 months later (vinc. Withheld)—shows normal swallow fx
  • Repeat VFSS was 5 months after last documentation of aspiration in June Patient now healthy
  • Cotton & Prescott
  • Tracheoesophageal septum separate these 2 structures at 35th day. Incomplete formation of tracheoesphageal septum results in TEF or LC. 3 1/2 weeks gestation. Cotton & Prescott.
  • Benjamin-Inglis Classification System 1989. Type 4 extends below the level of the thoracic inlet.
  • Type 1 supragottic, above the level of the TVF. Type 2 extend below the level of TVF. Type 3 with or without extension into Tracheoesphageal wall. Type 4 extends through the majority of the TE wall.
  • Type 1-4 from left to right. Slide courtesy of Dr. Reza Rahbar. 4 below the level of the thoracic inlet.
  • Photo of type 1 LC during DL. LC defect is in the lower right quadrant. Photo courtesy of Dr. Reza Rahbar.
  • These are S&S of an infant. S&S of older child: suspect LC if normal child with aspiration. These s&s mirror pharyngeal dysphagia. These s&s can be non-specific and must include a high suspicion for LC to prompt further investigation.
  • How to differentiate from other neurogenic swallow dysfx. LLL pneumonia, atelecticis, pulmonary findings. DLB, DL plus bronchoscopy, to see the changes in the lungs. X-ray showing non-specific infiltrates DLB must be done with “bimanual interaryntenoid palpation.” What about FEES?? WE DO NOT USE FEES AT OUR CENTER TO DX SWALLOWING DYSFX IN PEDS AT ALL AT THIS TIME. DLB IS GOLD STANDARD BUT THERE IS SOME THOUGHT THAT THE DX MAY BE SUBJECTIVE.
  • This suspicion of T1 LC arose when the incidence of isolated swallow dysfx increased in our pt population. The question then arose why are these pts aspirating? In collaboration with ORL, etc. the dx of LC became an option to consider.
  • Incidence of isolated LC regardless of type. Cotton, R.T. & Prescott, C.A.J. 1998. Congenital anomalies of the larynx. In Cotton, R.T. & Myer, C.M. (eds). Prescribed paediatric otolaryngology: 497-513. Philadelphia: Lippincott-Raven.
  • Our incidence rate is not currently available, but our numbers are in line with the most recent research and suggest and increased incidence rate compared to 0.1%. The 9 unrepaired patients are on an altered diet and closely monitored by PCP and ORL MD
  • The incidence at CHB is also higher than what has been reported in the past and is more comparable to MEEI than Cotton & Prescott. Chien et al 2006. Watters & Russell 2003 and Parsons et al 1998 (6.2% and 7.1 % incidence). Also large center studies.
  • PH syndrome: include summary. None of our patients have PH or G syndrome. Include other associated anomalies. It is the role of the MD to determine if LC is a marker for a syndrome. Often LC is with pts who have other medical issues. Of TEF pts 6% have LC. (Cotton & Prescott). The LC in these pts often goes undetected until persistent aspiration. PH: autosomal dominant, LC polydactayly, hyperpitutarism. G: dysphagia, hypospadias, hypertelorism, cleft L&P., tendency towards midline defects.
  • This must contribute to the higher incidence.
  • ID of this problem led to the development of CAD. PERHAPS THIS IS WHY WE HAVE INCREASED INCIDENCE DUE TO COLLABORATION AMONG CLINICIANS. All tertiary care medical centers need an airway center to provide the best care to these pediatric patients.
  • We see a number of patients who are normally developing, but have isolated swallow dysfunction with aspiration. When a pt has no underlying etiology for aspiration, one must consider LC as the differential diagnosis. VFSS does not diagnose LC. Must undergo direct laryngoscopy for definitive diagnosis (gold standard).
  • Robotic procedure eliminate the need for an incision. Intubation for 10 days post-op. This protocol for intubation 10 days post op is also being challenged. Least aggressive tx tried 1st.
  • Photos courtesy of Dr. Reza Rahbar. This is an example of an endoscopic repair of Type 1 LC provided by our surgeon. It demonstrates the suturing of the cleft and the less invasive method of repair compared to the open surgery.
  • 1-2 VFSS before the referral is made to ORL. When we see plateau and pattern then refer to ORL. Full recovery: on regular diet. Repeating VFSS too soon after surgery (1-2 weeks post-op) may continue to reveal aspiration which may likely be due to the surgery itself (swelling, inflammation).
  • Pt. accepted honey-thick liquids and nutrition determined well-hydrated
  • 4205990 powerpoint

    1. 1. Complex Decision Making in Pediatric Dysphagia Alana Lowry, MS, CCC-SLP Fletcher Allen Health Care Kara Fletcher Larson, MS, CCC-SLP Jennifer Miller, MS, CCC-SLP Children’s Hospital Boston ASHA November 17, 2006 Miami, Florida
    2. 2. Contact Information: <ul><li>Kara Fletcher Larson, MS, CCC-SLP </li></ul><ul><li>[email_address] </li></ul><ul><li>Alana Lowry, MS, CCC-SLP </li></ul><ul><li>[email_address] </li></ul><ul><li>Jennifer Miller, MS, CCC-SLP </li></ul><ul><li>[email_address] </li></ul>Lowry, Fletcher, Miller ASHA 2006
    3. 3. Incidence of Pediatric Dysphagia <ul><li>25% in all children </li></ul><ul><li>80% in children with developmental disabilities </li></ul><ul><li>3-10% of children exhibit severe feeding problems </li></ul><ul><li>Occur with greater prevalence in children with physical disabilities, medical illness and prematurity </li></ul><ul><li>(Manikam & Perman 2000) </li></ul><ul><li>Summarized in Oct. 2006 Brackett, Arvedson & Manno in SID #13 newsletter </li></ul>Lowry, Fletcher, Miller ASHA 2006
    4. 4. How did we get here? <ul><li>Major pediatric medical center </li></ul><ul><li>Children’s Hospital Boston, MA </li></ul><ul><li>2005 performed 864 pediatric videofluoroscopic swallow studies </li></ul><ul><li>Range in ages from 38 weeks PMA- young adults with developmental disabilities (early 20’s) </li></ul>Lowry, Fletcher, Miller ASHA 2006
    5. 5. Patient Demographics <ul><li>50% of our patients fall in the age range of 6 months- 3 years of age </li></ul><ul><li>6 % of patients referred from Level 3 NICU </li></ul><ul><li>4 % of patients referred by partnership with Dana Farber Cancer Institute/ Pediatric Oncology Division </li></ul><ul><li>13 % of patients referred by the Otolaryngology Division </li></ul>Lowry, Fletcher, Miller ASHA 2006
    6. 6. Trends in Referral Concerns <ul><li>Given high volume of VFSS performed we began to observe trends in subset of patient populations </li></ul><ul><li>Pediatric Oncology </li></ul><ul><li>Increased incidence in identification and diagnosis of the Type 1 laryngeal cleft </li></ul>Lowry, Fletcher, Miller ASHA 2006
    7. 7. Complex Decision Making <ul><li>Low incidence problems in pediatric dysphagia </li></ul><ul><li>High stakes for safe and effective management of oropharyngeal dysphagia </li></ul><ul><li>Medical, surgical, ethical and clinical questions we face when treating these children </li></ul><ul><li>Highlight the role of the SLP as the preferred provider of dysphagia services. </li></ul>Lowry, Fletcher, Miller ASHA 2006
    8. 8. Pediatric Oncology <ul><li>Patients referred for VFSS with chief complaint of coughing and choking with thin liquids </li></ul><ul><li>All patients referred were undergoing chemotherapy consisting of the drug Vincristine (enrolled in specific treatment protocol for type of cancer) </li></ul><ul><li>Onset of symptoms occurred 3-14 days during the treatment of a 6 week cycle </li></ul>Lowry, Fletcher, Miller ASHA 2006
    9. 9. Chemotherapy Agent: Vincristine <ul><li>Chemotherapy treats the type of cancer with medication that is toxic to tumor cells or kills them through interaction with receptors that indicate “programmed cell death” or prevent cell division. </li></ul><ul><li>Typically given in cycles </li></ul><ul><li>Cycle typically lasts 4-6 weeks </li></ul><ul><li>Period drug administration- resting period </li></ul>Lowry, Fletcher, Miller ASHA 2006
    10. 10. Side Effects of Vincristine: Neurotoxicity <ul><li>Involves peripheral, autonomic, and central neuropathy </li></ul><ul><li>Primary and dose limiting toxicity of Vincristine </li></ul><ul><li>Most side effects are dose related and reversible </li></ul><ul><li>Neurotoxicity can persist for months after discontinuation of therapy </li></ul><ul><li>Rare cases can be permanently disabling </li></ul>Lowry, Fletcher, Miller ASHA 2006
    11. 11. Results of VFSS in Children Receiving Vincristine <ul><li>All patients referred were full oral feeders at the time of referral </li></ul><ul><li>All patients undergoing intravenous administration of Vincristine </li></ul><ul><li>Parents report onset (often sudden) of sputtering, coughing and choking mainly with liquids </li></ul><ul><li>Attending oncologist referred patient for VFSS </li></ul>Lowry, Fletcher, Miller ASHA 2006
    12. 12. Results of VFSS in Children Receiving Vincristine <ul><li>Silent aspiration with thin liquids </li></ul><ul><li>Silent aspiration with thin and nectar thick liquids </li></ul><ul><li>Silent aspiration with thin, nectar and honey thick liquids </li></ul><ul><li>No evidence of aspiration with purees or solids </li></ul>Lowry, Fletcher, Miller ASHA 2006
    13. 13. Management of Pharyngeal Dysphagia in Children with Vincristine Toxicity <ul><li>Results reported back to Oncology Team </li></ul><ul><li>Based on the extent of aspiration modifications to the oral feeding regimen were initiated </li></ul><ul><li>In cases of aspiration with all liquid consistencies discussion regarding non-oral supplementation took place with the MD & Dysphagia Team </li></ul>Lowry, Fletcher, Miller ASHA 2006
    14. 14. Aspiration with Thin Liquid Only <ul><li>Diet of nectar thick liquids </li></ul><ul><li>Recommend referral to nutrition to ensure adequate hydration and child acceptance </li></ul><ul><li>Report results to Oncology Clinic </li></ul><ul><li>Medical team to discuss changes to dose/strength of Vincristine </li></ul><ul><li>Develop plan for repeat VFSS once team feels neurotoxicity is resolving </li></ul><ul><li>Parents also report improved clinical status which helps guide timeline for reassessment of swallow function </li></ul>Lowry, Fletcher, Miller ASHA 2006
    15. 15. Medical Concerns <ul><li>Larger medical concern whether to discontinue cycle of Vincristine to avoid further exacerbation of the toxicity vs. decreasing the dose/strength of the Vincristine. </li></ul><ul><li>Child may be made NPO with continuation of chemotherapy with dose changes. </li></ul><ul><li>Child put “on rest” from a swallowing standpoint with period of going off the drug </li></ul><ul><li>Above decision made by attending oncologist with input from the Oncology-Dysphagia team </li></ul>Lowry, Fletcher, Miller ASHA 2006
    16. 16. Medical-Ethical Considerations <ul><li>Decision to withhold chemotherapy treatment to allow neurotoxicity to improve </li></ul><ul><li>Parental stressors regarding decision </li></ul><ul><li>Patients taken off Vincristine for # weeks while swallow function improves </li></ul><ul><li>Child continues to orally feed with modifications in place </li></ul>Lowry, Fletcher, Miller ASHA 2006
    17. 17. Resolution of Swallow Function <ul><li>Swallow function resolved (returned to pre-Vincristine status) in 100% of patients. </li></ul><ul><li>Range of time it took for swallow function to return to normal </li></ul><ul><li>Normal defined as back to full oral diet of thin liquids, purees and solids </li></ul><ul><li># of VFSS patients underwent until swallow function resolved. (at what time intervals). </li></ul><ul><li>Recurrence once patient resumed Vincristine treatment </li></ul><ul><ul><li>Yes in some patients </li></ul></ul><ul><ul><li>Even at reduced strength of drug (50% strength). </li></ul></ul><ul><li>Oncology team was very conservative with re-starting chemotherapy/ altered doses and child monitored closely </li></ul>Lowry, Fletcher, Miller ASHA 2006
    18. 18. Case Study Vincristine Toxicity <ul><li>5/10/04: 3 ½ year old girl is diagnosed with </li></ul><ul><li>acute lymphoblastic leukemia (ALL) </li></ul><ul><li>Immediately begins chemotherapy (including vincristine) </li></ul><ul><li>Throughout 7 months of chemotherapy, pt. is seen frequently in clinic for “chronic upper respiratory tract congestion and persistent coughing” </li></ul>Lowry, Fletcher, Miller ASHA 2006
    19. 19. Case Study Vincristine Toxicity <ul><li>12/27/04: Diagnosed with pneumonia on chest x-ray </li></ul><ul><li>2/3/05: Pt. referred for initial VFSS by oncology team 9 months into chemotherapy treatments </li></ul><ul><li>VFSS revealed silent aspiration with thin liquids </li></ul><ul><li>Patient safe to continue to receive nectar-thick liquids, purees, and chewable solids </li></ul>Lowry, Fletcher, Miller ASHA 2006
    20. 20. Case Study: Vincristine Toxicity <ul><li>Insert VFSS # 1 of silent aspiration with thin liquids (2/3/05) </li></ul>Lowry, Fletcher, Miller ASHA 2006
    21. 21. Case Study Vincristine Toxicity <ul><li>2/4/05: Vincristine component of chemotherapy is withheld </li></ul><ul><li>Pt. remained on nectar-thick liquids, purees, solids </li></ul><ul><li>2/28/05: Repeat VFSS continued to reveal silent aspiration </li></ul><ul><li>with thin liquids </li></ul><ul><li>Recommendation: remain on altered oral diet </li></ul><ul><li>4/21/05: Repeat VFSS revealed normal swallow function with no documentation of aspiration with thin liquids </li></ul><ul><li>Respiratory status stable </li></ul>Lowry, Fletcher, Miller ASHA 2006
    22. 22. Case Study: Vincristine Toxicity <ul><li>Insert VFSS of normal swallow function with no aspiration (4/21/05) </li></ul>Lowry, Fletcher, Miller ASHA 2006
    23. 23. Case Study Vincristine Toxicity <ul><li>4/28/05: Vincristine resumed (50% strength) </li></ul><ul><li>(Pt. maintained nectar-thick liquid diet) </li></ul><ul><li>6/20/05: 2 mo. follow-up VFSS revealed silent aspiration with thin liquids </li></ul><ul><li>Recommendation: Cont. nectar-thick liquids </li></ul><ul><li>Pt. continues receiving vincristine </li></ul><ul><li>Pt. was asymptomatic from respiratory standpoint during this time </li></ul><ul><li>. </li></ul>Lowry, Fletcher, Miller ASHA 2006
    24. 24. Outcome: Case Study Vincristine Toxicity <ul><li>10/1/05: Patient completed course of chemotherapy </li></ul><ul><li>(No longer receiving vincristine) </li></ul><ul><li>11/3/05: Repeat VFSS was normal with no further evidence of aspiration with thin liquids </li></ul><ul><li>Pt. cleared for full oral diet </li></ul><ul><li>Follow-up: Patient tolerated re-introduction of thin liquids and maintained stable respiratory status </li></ul>Lowry, Fletcher, Miller ASHA 2006
    25. 25. Complex Decision Making in Pediatric Dysphagia Part 2 Type 1 Laryngeal Cleft
    26. 26. What is a Laryngeal Cleft (LC)? <ul><li>Communication between the posterior larynx and esophagus </li></ul><ul><li>Failure of tracheo-esophageal septum to develop </li></ul>Lowry, Fletcher, Miller ASHA 2006
    27. 27. Laryngeal Embryology <ul><li>Trachea and esophagus share common lumen during embryogenesis </li></ul><ul><li>35th day of gestation </li></ul><ul><li>Laryngeal cleft is the failure of the interarytenoid tissue or cricoid tissue to fuse in the posterior midline </li></ul>Lowry, Fletcher, Miller ASHA 2006
    28. 28. Types of Laryngeal Clefts <ul><li>Four classifications of laryngeal clefts </li></ul><ul><li>Type 3 and 4 diagnosed on first day of life due to severity </li></ul><ul><li>Type 1 and 2 diagnosis may take months to years. </li></ul><ul><li>Type 1 is the focus of our talk today. </li></ul>Lowry, Fletcher, Miller ASHA 2006
    29. 29. Classification of Laryngeal Clefts <ul><li>According to length </li></ul><ul><li>Type 1: interarynenoid only </li></ul><ul><li>Type 2: partial cricoid </li></ul><ul><li>Type 3: complete cricoid </li></ul><ul><li>Type 4: extending into trachea </li></ul>Lowry, Fletcher, Miller ASHA 2006
    30. 30. Lowry, Fletcher, Miller ASHA 2006 Classification of Laryngeal Clefts Benjamin and Inglis, 1989
    31. 31. Lowry, Fletcher, Miller ASHA 2006
    32. 32. Clinical Signs & Symptoms of Type 1 Laryngeal Cleft <ul><li>Noisy breathing </li></ul><ul><li>Inspiratory stridor </li></ul><ul><li>Coughing & choking with feedings </li></ul><ul><li>Chronic pulmonary infections </li></ul><ul><li>Aspiration </li></ul><ul><li>A’s and B’s with feedings </li></ul><ul><li>Cyanosis </li></ul>Lowry, Fletcher, Miller ASHA 2006
    33. 33. Differential Diagnosis of Type 1 LC <ul><li>VFSS (MBS) </li></ul><ul><li>FEES </li></ul><ul><li>Chest x-ray </li></ul><ul><li>Referral to pediatric Otolaryngologist and Pulmonologist </li></ul><ul><li>High degree of suspicion of type 1 laryngeal cleft (LC) </li></ul><ul><li>Direct laryngoscopy is needed for definitive diagnosis and is the gold standard for diagnosis </li></ul>Lowry, Fletcher, Miller ASHA 2006
    34. 34. Suspicion of Type 1 LC <ul><li>Child presents with normal development with exception of isolated swallowing dysfunction </li></ul><ul><li>No evidence of neurogenic, medical, and genetic etiology for swallow dysfunction. </li></ul>Lowry, Fletcher, Miller ASHA 2006
    35. 35. Incidence of Laryngeal Clefts (all types) <ul><li>Rare, less than 0.1% </li></ul><ul><li>Incidence increases to 0.6% in patients with the co-existence of TEF and laryngeal cleft </li></ul><ul><li>Strong association with other anomalies, but in our population has often existed in isolation </li></ul><ul><li>(Cotton & Prescott, 1998) </li></ul>Lowry, Fletcher, Miller ASHA 2006
    36. 36. Type 1 LC at Children’s Hospital Boston <ul><li>30 patients diagnosed with type 1 laryngeal cleft from 2000-2005. </li></ul><ul><li>21 patients repaired. </li></ul><ul><li>>90% patients with improved swallow function after repair. </li></ul>Lowry, Fletcher, Miller ASHA 2006
    37. 37. Incidence on the rise <ul><li>Literature review documents incidence of type 1 laryngeal cleft higher than in the past. </li></ul><ul><li>7.6% (Chien et al, 2006) </li></ul><ul><li>6.2% (Watters & Russell, 2003) </li></ul><ul><li>7.1% (Parsons et al, 1998) </li></ul><ul><li>Are there now more patients with type 1 laryngeal cleft or are we getting better at the diagnosis? </li></ul>Lowry, Fletcher, Miller ASHA 2006
    38. 38. Associated Congenital Anomalies with laryngeal cleft <ul><li>Pallister-Hall Syndrome </li></ul><ul><li>G Syndrome </li></ul><ul><li>TEF </li></ul><ul><li>Esophaeal Atresia and Stenosis </li></ul>Lowry, Fletcher, Miller ASHA 2006
    39. 39. Team Approach to Differential Diagnosis <ul><li>SLP (pediatric feeding & swallowing specialist) </li></ul><ul><li>Otolaryngologist (ENT) </li></ul><ul><li>Pulmonologist </li></ul><ul><li>Gastroenterologist </li></ul><ul><li>Radiologist </li></ul><ul><li>Developmental Pediatrician </li></ul>Lowry, Fletcher, Miller ASHA 2006
    40. 40. Center for Aerodigestive Disorders (CADD) <ul><li>Monthly meeting to review complex cases and collaborate on differential diagnosis </li></ul><ul><li>Multidisciplinary team approach to diagnosis and treatment for aerodigestive cases </li></ul><ul><li>CADD clinic meets 1x per month </li></ul><ul><li>Patients see GI, ORL, Pulmonary and VFSS on same day </li></ul>Lowry, Fletcher, Miller ASHA 2006
    41. 41. Typical course of patient <ul><li>VFSS: documentation of aspiration of thin liquids </li></ul><ul><li>Unable to visualize laryngeal cleft on fluoroscopy </li></ul><ul><li>Patient placed on treatment of thickened liquids </li></ul><ul><li>PCP referral to Otolaryngologist for further assessment </li></ul>Lowry, Fletcher, Miller ASHA 2006
    42. 42. Alternate treatments for Type 1 LC <ul><li>Identification and management of GERD </li></ul><ul><li>Thickened liquids </li></ul><ul><li>NG-tube or G-tube </li></ul><ul><li>These treatments may be implemented prior to surgical repair </li></ul>Lowry, Fletcher, Miller ASHA 2006
    43. 43. Surgical treatment of Type 1 LC <ul><li>Historically, an invasive surgical procedure </li></ul><ul><li>Endoscopic procedure </li></ul><ul><li>Robotic Procedure at Children’s Hospital Boston </li></ul>Lowry, Fletcher, Miller ASHA 2006
    44. 44. Laryngeal Cleft Endoscopic repair Lowry, Fletcher, Miller ASHA 2006
    45. 45. Timeline from diagnosis to recovery <ul><li>VFSS </li></ul><ul><li>ORL consult </li></ul><ul><li>Direct laryngoscopy </li></ul><ul><li>Maintenance diet </li></ul><ul><li>Repair </li></ul><ul><li>Repeat VFSS 6-8 weeks after repair </li></ul><ul><li>Full recovery not documented on VFSS until 2-10 months post surgery </li></ul>Lowry, Fletcher, Miller ASHA 2006
    46. 46. Case Study Laryngeal Cleft <ul><li>16-month-old boy with normal growth and development </li></ul><ul><li>Admitted to CHB for: -respiratory distress </li></ul><ul><li>-fever of 102 ° </li></ul><ul><li>-perioral cyanosis </li></ul><ul><li>-mother reports history of 6 episodes of pneumonia in the past 5 months (all LLL) </li></ul>
    47. 47. Case Study Laryngeal Cleft <ul><li>Videofluoroscopic swallow study performed during admission: </li></ul><ul><ul><li>Revealed: </li></ul></ul><ul><ul><li>silent aspiration with thin liquids </li></ul></ul><ul><ul><li>silent aspiration with nectar-thick liquids </li></ul></ul><ul><ul><li>Safe to consume honey-thick liquids, purees and chewable solids orally </li></ul></ul><ul><ul><li>Recommended nutrition consult to assess hydration needs on honey-thick liquids </li></ul></ul>Lowry, Fletcher, Miller ASHA 2006
    48. 48. Case Study: Laryngeal Cleft <ul><li>INSERT VFSS HERE of pt. aspirating with thin and nectar-thick liquids </li></ul>Lowry, Fletcher, Miller ASHA 2006
    49. 49. Case Study Laryngeal Cleft <ul><li>PCP referral to Otolaryngology (ORL) </li></ul><ul><ul><li>Direct laryngoscopy and bronchoscopy performed </li></ul></ul><ul><ul><li>Type I laryngeal cleft diagnosed. </li></ul></ul><ul><li>1 month later: endoscopic repair of Type I laryngeal cleft by ORL </li></ul><ul><li>Sent home after surgery on honey-thick liquids (same pre-operative diet) </li></ul><ul><li>Repeat VFSS 4 ½ months s/p repair revealed no aspiration with thin and nectar-thick liquids </li></ul><ul><li>Patient cleared for unrestricted oral diet </li></ul>Lowry, Fletcher, Miller ASHA 2006
    50. 50. Summary: Vincristine Toxicity in Pediatric Pharyngeal Dysphagia <ul><li>Low incidence problem but with significant consequences for pulmonary health, swallow function and treatment decisions. </li></ul><ul><li>Increased awareness to respiratory symptoms in pediatric patients undergoing chemotherapy treatment. </li></ul><ul><li>Decreased referral time. </li></ul><ul><li>Highlights the importance of the role of the SLP on the dysphagia-oncology team. </li></ul>Lowry, Fletcher, Miller ASHA 2006
    51. 51. Complex Decision Making in Pediatric Dysphagia Lowry, Fletcher Larson & Miller, 11-17-06 References <ul><li>Benjamin B, Inglis A. Minor congenital laryngeal clefts: diagnosis and classification. Ann Otol Rhinol Laryngol 1989;98:417-420. </li></ul><ul><li>Bermudez, M., Fuster, JL, Llinares, E., Galera, A, Gonzalez, C. Intraconazole-related increased vincristine neurtoxicity: case report and review of literature, Journal of Pediatric Hematology & Oncology, 2005, July 27(7): 389-92. </li></ul><ul><li>Boseley, Mark et al., The utility of fiberoptic endoscopic evaluation of swallowing (FEES) in diagnosing and treating children with Type 1 laryngeal clefts. International Journal of Pediatric Otorhinolaryngology (2006) 70, 339-343. </li></ul><ul><li>Chien, Wade et al., Type 1 laryngeal cleft: Establishing a functional diagnostic and management algorithm, International Journal of Pediatric Otorhinolaryngology (2006). Article in press. </li></ul><ul><li>Cotton, R.T. & Prescott, C.A.J. 1998. Congenital anomalies of the larynx. In Cotton, R.T. & Myer, C.M. (eds). Prescribed paediatric otolaryngology: 497-513. Philadelphia: Lippincott-Raven. </li></ul><ul><li>Jeng, MR, Feusner, J. Itraconazole-enhanced vincristine neurotoxicity in a child with acute lymphoblastic leukemia. Pediatric Hematology & Oncology. 2001, March: 18 (2): 137-42. </li></ul><ul><li>Langmore, Susan. Evaluation of oropharyngeal dysphagia: which diagnostic tool is superior, Curr. Opin. Otolaryngol. Head Neck Surg. 11 (2003) 485-489. </li></ul><ul><li>Parsons, D, Stivers, F, Giovaeto, D, Phillips, S. Type1 posterior laryngeal clefts, Laryngoscope 108, March 1998. 403-410. </li></ul><ul><li>Schulmeister, Lisa, RN, MN, CS, OCN. Preventing Vincristine Sulfate Medication Errors. Oncology Nursing Forum, Volume 3, No. 5, E90-E98. </li></ul><ul><li>Watters, K, Russell, J. Diagnosis and management of type 1 laryngeal cleft, Int. J. Pediatric Otorhinolaryngology. 67, June 2003. 591-596. </li></ul>Lowry, Fletcher, Miller ASHA 2006