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Original Investigation |

Usefulness of Upper Airway Endoscopy in the Evaluation of Pediatric Pulmonary Aspiration

Eelam Adil, MD, MBA1,2; Ozgul Gergin, MD1; Kosuke Kawai, ScD1,3; Reza Rahbar, DMD, MD1,2; Karen Watters, MB, BCH, MPH1,2
[+] Author Affiliations
1Department of Otolaryngology and Communication Enhancement, Boston Children’s Hospital, Boston, Massachusetts
2Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts
3Clinical Research Center, Boston Children’s Hospital, Boston, Massachusetts
JAMA Otolaryngol Head Neck Surg. 2016;142(4):339-343. doi:10.1001/jamaoto.2015.3923.
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Importance  There is no consensus on the evaluation of pediatric patients with aspiration.

Objectives  To determine the yield of direct laryngoscopy and bronchoscopy (DLB) using general anesthesia in pediatric patients who aspirate and to identify clinical predictors of aspiration-related airway lesions.

Design, Setting, and Participants  Retrospective review at a tertiary referral children’s hospital. A medical record review was performed on all patients with a documented diagnosis of pulmonary aspiration who underwent DLB using general anesthesia during a 5-year period (January 2010 to December 2014).

Intervention  Direct laryngoscopy and bronchoscopy using general anesthesia.

Main Outcomes and Measures  Data were collected and analyzed, including age, sex, history of intubation, flexible laryngoscopy results, DLB findings, recurrent pneumonia, and associated diagnoses.

Results  Five hundred thirty-two patients met the inclusion criteria. Their mean (SD) age was 2.2 (3.6) years (age range, 0.1-25.0 years), with more than half younger than 1 year. Sixty-two percent (328 of 532) of the participants were male. Flexible laryngoscopy examination alone identified 93 patients with an airway lesion. Direct laryngoscopy and bronchoscopy identified 173 additional diagnoses and had a greater diagnostic yield for airway lesions (45.1% [240 of 532]) than flexible laryngoscopy examination alone (P < .001). Patients with an aspiration-related airway lesion were older (mean [SD] age, 2.7 [3.8] vs 2.2 [3.8] years; P = .02) and more likely to have another aerodigestive disorder than were patients without an airway lesion (21.7% vs 11.6%; P = .004). Older age (adjusted risk ratio [95% CI], 1.37 [1.08-1.73]; P = .01), recurrent pneumonia (1.40 [1.11-1.76]; P = .004), and history of intubation (1.35 [1.07-1.70]; P = .01) were significantly associated with the presence of an aspiration-related airway lesion in the multivariable model. Patients with an aspiration-related airway lesion were less likely to have neurologic disease than were patients without an airway lesion (0.50 [0.34-0.73]; P < .001). In all, 66.3% of patients (110 of 166) eventually underwent surgical repair of an identified aspiration-related airway lesion.

Conclusions and Relevance  In children with chronic aspiration who warrant further evaluation, flexible laryngoscopy alone is not sufficient. There is a high incidence of aspiration-related airway lesions identified on DLB and not seen on flexible laryngoscopy, with 66.3% (110 of 166) of those lesions eventually requiring surgical intervention. Patients 1 year or older with a history of recurrent pneumonia or intubation are more likely to have an aspiration-related airway lesion.

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Figure.
Comorbidities in the Study Population

Patients with aerodigestive comorbidities that were seen as part of a syndrome or association were included under the Syndrome category, and those with an isolated anomaly were included in the Other Aerodigestive Disorder category. ASD indicates atrial septal defect; BPD, bronchopulmonary dysplasia; CHARGE, coloboma (of eyes), hearing deficit, choanal atresia, retardation of growth, genital defects (males only), and endocardial cushion defect; EA, esophageal atresia; PDA, patent ductus arteriosus; TEF, tracheoesophageal fistula; TOF, tetralogy of Fallot; VACTERL, vertebral, anal, cardiac, tracheal, esophageal, renal, and limb abnormalities; and VSD, ventricular septal defect.

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