QUAD #25: Medical Management of Minor Laryngeal Clefts with Dr. Greg Burg

Globalcast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hi everyone, I'm Em Gody from Cincinnati Children's Hospital Medical Center. In October 2022, Cincinnati Children's hosted the Quad conference, which was a combination of four conferences, the International Organization for Esophageal Atresia, the Aerodigestive Society conference, the Cincinnati Children's Airway course, and the Cincinnati Children's Pediatric Dysphagia series. In this video, we are going to talk about medical management of laryngeal clefts with Dr. Greg Bird, a pulmonologist at Cincinnati Children's. Let's start with a case. This is a 5-year-old trach-dependent patient who had encephalopathy, wants to get her trach out, does okay with capping, and is mainly fed PO, has a G-tube in place though. And they came to us to look at getting decannulated. We learned from Dr. Bird that unfortunately a flexible bronchoscopy is quite limited in evaluating a cleft unless it's a major cleft. This patient has secretions in the lower airway and there's a diffuse mucopurulent bronchitis, looking at the MLB portion and we'll come back and check for a cleft here. Dr. Bird's team called this a deep notch, which they would consider a minor cleft. But the child more functionally clearly is aspirating and there's some more information that helps to build that case. The medical management of these patients helps drive some of the decisions in terms of what to do with it, whether it's a type one cleft or an interarytenoid notch. This child had a very inflammatory pattern on the bronchoalveolar lavage, did not have any lipid-laden macrophages despite being orally fed, so that was interesting. Respiratory cultures showed predominantly upper airway flora. And then also had two candida species grow in the mucopurulent bronchitis. So in terms of what we do with these clefts, I think a lot of it has to do with how bad is the child. And that a lot of that comes down to the degree of aspiration. And so some of the things that we look at and we see a lot of these patients the day before endoscopy and pulmonary clinic. And they're talking about how sick they are. Are they coughing? Are they having sick visits? Are they come to the emergency room often? Do they get hospitalized? Then we look at our bronchoscopic findings. Do you see a lot of airway edema? Do you see the tracheal rings well or do you see edema throughout the trachea? In this child, they saw a lot of mucus plugging and secretions. And then we look at the microlaryngoscopy and bronchoscopy or MLB. And we either define it's a notch or a type one cleft. Well we're also looking for other airway lesions as well. I would theorize that patients that have significant tracheomalacia or upper airway obstruction from things like tonsils and adenoids. They sometimes have to generate greater forces with their respiratory mechanics and that pushes more air across the glotus and can increase the risk of aspiration. Bronchoscopically, we look at the BAL and we look at what kind of inflammatory cells are there. What do the cultures show and what's in the macrophages? We also talked a little bit about some of the swallowing assessments. First thing is what do the parents tell you? Kid comes to clinic and the parents say, every time they have a cup of water, they choke and cough. You're already suspecting that there may be a minor cleft. Never hurts to watch a feeding. I found that to be very useful. Sometimes we consider differential imaging. Probably the most important one here is the chest CT, where we're looking for chronic changes related to aspiration. I think a child, if they have a deep interarytenoid notch and you have some support of aspiration on one of your prior studies, either a BAL or one of these other assessments, and you have bronchiectasis, then you're going to be inclined to repair that or build up that notch. And then if there's patients that you have an interarytenoid notch, you have a genetic component and you're worried about central control of swallowing, you may check a brain MRI. You're looking for some of those neurologic and functional comorbidities and you want to assess other pathologies that could increase your risk of aspiration. In terms of the medical management, we work with our speech therapist pretty closely on safe swallow. And so a lot of patients will do well with some form of thickening, some pacing, and potentially changing the volume that they're getting. They will use G-tubes and NG-tubes as needed for nutritional intake. And Dr. Bird talks to families and tells them, so you can aspirate from three different locations, things that start in your upper airway, things you put in your upper airway, and things that come up from your GI system. And they work on teaching what is safe to put in your mouth, what is safe to swallow, and they look at patients that have excessive drooling and come up with a couple of different options for medical management to reduce that risk. And then we talk about, are there issues with your esophagus or your GI motility that increase the risk of vomiting and aspirating or reflux and aspiration. Some of the pulmonary therapies they use are mostly considered as a band-aid. These are reactive therapies. We may try inhaled steroids to reduce inflammation. They also can try chronic macrolide therapy as an anti- neutrophilic, which came out of the cystic fibrosis literature. And then we'll use different saline to thin out secretions. We may use albuterol to help bronchodilate if there's a history of sort of a reactive airway component to this aspiration pneumonitis. If patients have significant tracheomalacia, they may use ipratropium over albuterol. And then there's patients that will have to augment the airway clearance for and a lot of these may be your neuro-devastated or your musculoskeletally limited patients that maybe don't have a good cough or are unable to clear their airways. And then Dr. Bird mentioned that one of the other responsibilities they have as pulmonologist is, how do they work on health maintenance and counseling these families. And this is probably true for any lung disease, but particularly for patients that are at risk for aspiration is, do we recommend vaccinating them against respiratory illnesses and reducing their risk of environmental hazards, including smoke. If you're going to monitor these patients and not intervene operatively, pulmonologist watch the clinical symptoms and they reassess all factors that we mentioned previously in this video. What are their clinical symptoms? How are they doing? Are they keeping up with others? Are they getting hospitalized? Have they responded to any of the interventions we've done? And so we see how they do and then we may re-rescope them at some point and reassess their swallow. And then over time, that's how we decide whether they should have anything further done. In summary, managing minor laryngeal cleft patients focuses on the severity of aspiration and symptoms like coughing and airway inflammation, utilizing both medical and surgical interventions as necessary. Key assessments include bronchoscopy, swallow studies, and imaging such as chest CT scans. Treatment approaches involve safe swallowing techniques, dietary modifications, and pulmonary therapies. Long-term care focuses on monitoring symptoms, reassessing swallowing function, and promoting overall health through vaccinations and minimizing environmental risks. Thank you for watching this video. Don't forget to subscribe to the Stay current MD YouTube channel. Follow our social media channels and download the Stay current MD app for tons of content in pediatric surgery. Globalcast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.