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Pediatric videostroboscopy
- 1. PediatricPediatric VideostroboscopyVideostroboscopy ENT Department. Hospital de Niños “J.M de los Ríos”. Caracas- Venezuela Dr. M.Adriana Pérez, Dr. Victoria Tenías, Dr. Jacqueline Alvarado, Dr. Ligia Acosta, Dr. Yanet bastidas, Dr. Marisol Díaz
- 2. Well known use of videostroboscopy Minor Structural Alterations of larynx (Paulo Pontes Brasil 1994): Laryngeal Asymmetry Posterior fusion incomplete Glottic disproportion Alteration of focal fold cover Chronic Dysphonia Congenital origin? BackgroundBackground
- 3. Design a protocol for performing videostroboscopy in children Point out usefulness of previous training for children below 8 years old Precise incidence of minor structural alterations of larynx in pediatric population ObjectivesObjectives
- 4. Prospective and descriptive study Aug 2008 - Aug 2009 165 Dysphonic patients 33 patients (+24m) Between 4 and 18 years old / 21 M – 12 F Exclusion criteria.: Cranial and facial dimorphism Puberphonia Laryngeal Papillomatosis Vocal fold paresis Laryngeal previous surgery Methods IMethods I
- 5. History of Dysphonia Methods IIMethods II
- 6. History of Dysphonia Methods IIMethods II
- 7. Transnasal Flexible Fibroptic evaluation Methods IIMethods II Aritenoids mobility Vocal fold Lesions
- 8. Videostroboscopic assessment: Mother training/child training: minimal 2 weeks Gag reflex: metoclorpamide if needed Methods IIMethods II
- 10. ResultsResults Distribution of Minimal Structural Alterations in patients with dysphonia N= 165
- 11. ResultsResults N= 33 Distribution by age of patients with minimal structural alterations
- 12. ResultsResults Distribution of minimal structural alterations types
- 13. ResultsResults Number of failed intents by age
- 14. -All patients trained. -21% (7) needed “ a second chance” -9% (3) needed a “ third chance” -Ages 7 to 10 more affected -More frequent lesion: sulcus vocalis -All (33 pts) had Minimal Structural Alterations. ConclusionsConclusions
- 15. - Videostroboscopy can be done in pediatric patients -Minimal structural alterations could have a congenital origin -Voice therapy can be follow up in children's -Management of dysphonic patients could be done more accurately in pediatric patients ConclusionsConclusions
- 16. THANK YOU
Editor's Notes
- Good Morning
- It's well known the absolute and important use of videostroboscopy for the diagnosis of vocal fold mucosa lesions, but it's also known that this can be very difficult to do in children because their lack of collaboration and tolerance to this type of study. Also, we know that in the Brazilian and Latin-American papers since 1995 Dr. Paulo Pontes and Mara Behlau described some minor structural alterations that probably are only anatomical variation but also can be minor congenital malformation at the vocal fold level, and this could lead to chronic dysphonia. So, looking for this kind of alterations of larynx in pediatric population probably can determine the congenital origin.
- That´s why our goals were design a protocol that could help use to do this study in children, and this would point out the usefulness of previous training for children below 8 years old, leading to the knowledge of this minor structural alterations in young population.
- How we did this? This was a clinical, prospective and descriptive study Investigation design was non-experimental Poblation: from a universe of 165 dyshponic patiens that consulted our department since august 2008 until august 2009 we study 33 patients that had dysphonia for more than 24 months, that had an exacerbation and without any other condition that could explain the cause of dysphonia. This patients were between 4 and 18 years old , 21 males and 12 females. Our exclusion criteria were…..
- We did a 3 step study, the first step was filling in the dysphonia patients chart , we asked about every detail about the onset of the symptom also personal and familiar background.
- At the same time we did value subjetively charachteristics of the voice with de GRBAS grading system (grade, roughness, breathness, asthenia, strenght.
- A transnasal flexible fibroptic evaluation were performed to evaluate aritenoids mobility, vocal fold mobility, and lesions in suproglottic, glottic and subglottic regions, most of the time we didn´t find any cause for dysphonia, thats the time when we decide to do videostroboscopy
- For videostroboscopic assessment we did train mom and child. First we told mom to sit and stuck the tongue out of her mouth, with our gloves on we hold her toung out and with a tongue depressor we did a mild to moderate pressure above the tongue during 30 seconds and we told her to don´t swallow during that time, after that we sat the child into mom´s lap and did the same to them. We told mom to do this frequently during the day at home, as a game during 2 weeks or more. If when we did the transnasal evaluation the patient had an increased gag reflex we calculate a dose of metoclorpramide and told mom to give to the child the day before and same day of the study. A great amount of patient was needed too. Before carring out the videostroboscopy we record child voice and wrote down fundamental frequency for posterior analyses
- For videostroboscopic assessment we did train mom and child. First we told mom to sit and stuck the tongue out of her mouth, with our gloves on we hold her toung out and with a tongue depressor we did a mild to moderate pressure above the tongue during 30 seconds and we told her to don´t swallow during that time, after that we sat the child into mom´s lap and did the same to them. We told mom to do this frequently during the day at home, as a game during 2 weeks or more. If when we did the transnasal evaluation the patient had an increased gag reflex we calculate a dose of metoclorpramide and told mom to give to the child the day before and same day of the study. A great amount of patient was needed too. Before carring out the videostroboscopy we record child voice and wrote down fundamental frequency for posterior analyses
- We found from our 165 patients with dysphonia that the 33 patients that we did videostroboscopy all of them had minor structural alterations,
- Patients between 7 and 10 years old present with more dysponia (48,49%) and had the higher number of minor structural changes
- We found in the minimal structural alteration different kind of finds, undifferianted lesions were 21%, sulcus vocalis were 39% also the epithelial cyst, a 3% for mucosal bridges, microweb presented in patients were 18%, and augmentation of vascular patterns known as “vasculodisgenisia” were also 3%
- We did also quantify the number of failed intents and in which age was frequently expected so we needed to give a “ second chance” more to preschool children and a “third chance” more in the 7 to 10 years old patients, this patients were more prone to be scared.
- We can summarize that all patients were trained at least for 2 weeks, some of them needed anti gag-reflex drugs, 7 patients of 33 needed a second chance and only 3 needed a third chance. Sulcus vocalis were found more frequently in this patients. Patient with 7 years old to 10 were more dysphonic propably because this are school years and the do a lot of shouting, and all of them had minimal structural alterations probably predisposing for dysphonia.
- So videostroboscopy CAN be done in pediatric patients with training mom and child as a game and with patience, our youngest patient was a 4 year old female that we trained during 3 weeks, she was gorgeous!. All patients had a minimal structural alteration af the vocal fold cover so we can expect to be a congenital origin. In this patients we can follow up voice therapy doing this procedure, this leads to a better carriyng out of dysphinic patients, we can manage them more accurately and also we can decide when a to whom we are going to do surgery same as adults.