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Original Investigation |

Modified Best-Practice Algorithm to Reduce the Number of Postoperative Videofluoroscopic Swallow Studies in Patients With Type 1 Laryngeal Cleft Repair

Carissa Wentland, DO1; Cheryl Hersh, MA, CCC-SLP2; Sarah Sally, MS, CCC-SLP2; M. Shannon Fracchia, MD3; Steven Hardy, MD4; Bob Liu, PhD5; Jordan A. Garcia, BS6; Christopher J. Hartnick, MD1
[+] Author Affiliations
1Pediatric Otolaryngology Service, Massachusetts Eye and Ear, Boston
2Department of Speech, Language and Swallowing Disorders, Massachusetts General Hospital, Boston
3Pediatric Pulmonology Service, Massachusetts General Hospital, Boston
4Pediatric Gastroenterology Service, Massachusetts General Hospital, Boston
5Department of Imaging, Massachusetts General Hospital, Boston
6Department of Otolaryngology (ENT), Harvard Medical School, Massachusetts Eye and Ear, Boston
JAMA Otolaryngol Head Neck Surg. 2016;142(9):851-856. doi:10.1001/jamaoto.2016.1252.
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Importance  There is no consensus as to the timing of videofluoroscopic swallow studies (VFSSs) in determining resolving aspiration after laryngeal cleft repair. There is a growing literature on the effect of radiation exposure in children.

Objective  To modify a previously published best-practice algorithm based on a literature review and our clinical experience to maintain the quality of care provided after successful type 1 laryngeal cleft repair, while reducing the total number of postoperative VFSSs by 10% or greater.

Design, Setting, and Participants  The previously published algorithm was modified by a multidisciplinary group at a tertiary care academic medical center (Massachusetts Eye and Ear) and was prospectively applied to 31 children who underwent type 1 laryngeal cleft repair from January 1, 2013, to February 28, 2015.

Main Outcomes and Measures  The number of VFSSs obtained in the first 7 months after surgery was compared with the peer-reviewed literature and with a retrospective cohort of 27 patients who underwent type 1 laryngeal cleft repair from January 1, 2008, to December 31, 2012.

Results  The study cohort comprised 31 patients. Their ages ranged from 10 to 48 months, with a mean (SD) age of 23.94 (9.93) months, and 19% (6 of 31) were female. The mean (SD) number of postoperative VFSSs per patient before and after implementation of the algorithm was 1.22 (0.42) and 1.03 (0.55), respectively. The use of the algorithm reduced the number of VFSSs by 0.19 (95% CI, −0.07 to 0.45). This reduction in radiation exposure is equivalent to 1.47 chest radiographs per child per course of care. Surgical success was 87% (27 of 31) compared with our group’s previously published success rate of 78% (21 of 27) (absolute difference, 0.09; 95% CI, −0.17 to 0.34).

Conclusions and Relevance  This modified algorithm to help guide decisions on when and how often to obtain VFSSs after type 1 laryngeal cleft repair can limit patients’ radiation exposure, while maintaining high surgical success rates.

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Figure 1.
Modified Best-Practice Algorithm

VFSS indicates videofluoroscopic swallow study.

aSymptomatic laryngeal penetration such that the patient required a thickened diet before surgery.

bComorbidities that included cardiorespiratory disease, congenital syndromes, or known neuromuscular disorder (eg, hypotonia or seizure disorder).

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Figure 2.
Number of Videofluoroscopic Swallow Studies (VFSSs) and Swallow Results After Implementation of the Modified Algorithm in 31 Patients

The figure shows the number of patients in each arm of the algorithm, the number of VFSSs each group received, and the resolution of aspiration in each group.

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