September 2019 HSC Section 1 Congenital and Pediatric Problems

TABLE II. Types of Graft Used For Laryngotracheal Reconstruction (n 5 54).

TABLE III. Univariate Analysis of Associations ( b ) Between Baseline Charac- teristics; Preoperative Factors; Postoperative Factors; and Total pVHI, VAS, and Total DSI Outcome.

Only anterior graft

1

Only posterior graft

3

pVHI

VAS

DSI

Anterior graft 1 posterior split

2

Biographical data Age at time of follow-up (years)

Anterior 1 posterior graft

48

2 0.101

0.164

0.321

Total laryngotracheal reconstruction

54

Gender*

2 0.028

2 0.018

0.136

Operative factors Age at time of surgery (years) Tracheostomy present? † Co-morbidities present? † Glottic involvement? † Cotton-Myer grade stenosis ‡

of data is not feasible due to the strong heterogeneity of the studies and of the methods used. The objective measurement of voice quality in chil- dren proves to be a challenge, and there is no consensus on the best tool for this purpose. We have used the DSI in an attempt to quantify the voice quality of our subjects. A large number of children could not comply with the study protocol, and interpretation of outcome is difficult because no norm values exist for pediatric population. A small number of studies have reported on DSI outcome in children. The normal DSI values for children differ strongly in these studies. This is also due to the fact that the use of different analysis software influences the total DSI score. Considering the published studies and our own experience with the DSI as an outcome measure for voice quality, we have determined a score higher than 2.0 to be normal for the pediatric popula- tion. 13–16 Of our study population, no less than 77% of the patients had a clinically significant voice disturbance with a DSI score below 2.0. The pVHI is a validated and easy-to-use tool in assessing voice-related quality of life in the pediatric population. 9 It has successfully been used in a number of studies on voice outcome after pediatric airway sur- gery. 9,19 Using the pVHI, we were able to identify signif- icant factors for poor pVHI questionnaire outcome after long-term follow-up: glottic involvement of the stenosis and the presence of comorbidities in which BPD, trache- omalacia, and congenital syndromes were the most common. The presence of glottic stenosis and of comorbidities were also the most important factors in our previous

2 0.116

2 0.047

0.436

2 0.265

0.149

0.320

2

0.180

2 0.257

0.359

0.001

0.489

0.352

2 0.934

2 0.051

2 0.237

Congenital syndrome † Posterior graft used †

0.057

0.021

0.079

0.211

0.242

2 0.076

Postoperative health status Stridor †

2 0.271

0.554

0.406

Bruce treadmill test, SD score

2 0.264

2 0.160

0.007

FiV1%VCmax in %

0.004

0.539

0.413

2

2

VCmax SD

0.170

0.139

0.082

PEF SD

2 0.317

2 0.137

0.067

FeV1 SD

2 0.145

2 0.194

0.015

Significant associations ( P < 0,05) are given in bold italics. *female 5 0; male 5 1. † no 5 0; yes 5 1. ‡ C-M grade 1 & 2 5 0; C-M grade 3 & 4 5 1.

FeV1 5 forced expiratory volume in 1 second; FiV1 5 forced inspira- tory volume in 1 second; PEF 5 peak expiratory flow; SD 5 standard devi- ation; VCmax 5 maximum vital capacity.

reports on functional outcome and HR-QoL. 2,3 These findings have triggered us to reconsider the single-stage LTR approach in cases for which glottic involvement of the stenosis is apparent. One could argue for the use of postoperative stents in cases of extensive glottic scarring in order to keep the glottis abducted in the healing phase after laryngeal reconstruction. 20 Although this approach could work for a more patent airway, it could have a worsening effect on voice quality. Unfortunately,

TABLE IV. Results From Multivariate Linear Regression Model.

R 2

Operative Factors

Constant

Unstandardised

SE

Standardized

P Value

Total pVHI (n 5 55)

Glottic involvement*

2.857

4.826

1.284

0.426

< .01

0.33

Comorbidity*

4.152

1.268

0.371

< .01

Follow-up Health Status Total pVHI score (n 5 35) Audible stridor a

13.49

4.88

1.50

0.44

< .01

0.45

FiV1%VCmax in %

2 0.13

0.04

2 0.42

< .01

pVHI VAS (n 5 35)

FiV1%VCmax in %

0.87

2 0.01

2 0.00

2 0.42

0.01

0.18

*no 5 0; yes 5 1. FiV1 5 forced inspiratory volume in 1 second; pVHI 5 pediatric voice handicap inventory; SE 5 standard error; VAS 5 visual analogue scale; VCmax 5 maximum vital capacity.

Laryngoscope 127: July 2017

Pullens et al.: Voice Outcome After Pediatric Airway Surgery

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