complex decision making in pediatric dysphagia

Complex Decision Complex Decision Making in Pediatric Making in Pediatric

DysphagiaDysphagiaAlana Lowry, MS, CCC-SLPAlana Lowry, MS, CCC-SLPFletcher Allen Health CareFletcher Allen Health Care

Kara Fletcher Larson, MS, CCC-SLPKara Fletcher Larson, MS, CCC-SLPJennifer Miller, MS, CCC-SLPJennifer Miller, MS, CCC-SLP

Children’s Hospital BostonChildren’s Hospital BostonASHA November 17, 2006ASHA November 17, 2006

Miami, FloridaMiami, Florida

Lowry, Fletcher, Miller ASHA 2006

Contact Information:Contact Information:

Kara Fletcher Larson, MS, CCC-SLPKara Fletcher Larson, MS, CCC-SLP [email protected]@childrens.harvard.edu

Alana Lowry, MS, CCC-SLPAlana Lowry, MS, CCC-SLP [email protected]@vtmednet.org

Jennifer Miller, MS, CCC-SLPJennifer Miller, MS, CCC-SLP [email protected]@childrens.harvard.edu

mailto:[email protected]




Incidence of Pediatric DysphagiaIncidence of Pediatric Dysphagia

25% in all children25% in all children 80% in children with developmental disabilities80% in children with developmental disabilities 3-10% of children exhibit severe feeding 3-10% of children exhibit severe feeding

problemsproblems Occur with greater prevalence in children with Occur with greater prevalence in children with

physical disabilities, medical illness and physical disabilities, medical illness and prematurityprematurity

(Manikam & Perman 2000)(Manikam & Perman 2000) Summarized in Oct. 2006 Brackett, Arvedson & Manno in SID #13 newsletterSummarized in Oct. 2006 Brackett, Arvedson & Manno in SID #13 newsletter


How did we get here?How did we get here?

Major pediatric medical centerMajor pediatric medical center Children’s Hospital Boston, MAChildren’s Hospital Boston, MA 2005 performed 864 pediatric videofluoroscopic 2005 performed 864 pediatric videofluoroscopic

swallow studiesswallow studies Range in ages from 38 weeks PMA- young Range in ages from 38 weeks PMA- young

adults with developmental disabilities (early 20’s)adults with developmental disabilities (early 20’s)


Patient DemographicsPatient Demographics

50% of our patients fall in the age range of 6 50% of our patients fall in the age range of 6 months- 3 years of agemonths- 3 years of age

6 % of patients referred from Level 3 NICU6 % of patients referred from Level 3 NICU 4 % of patients referred by partnership with 4 % of patients referred by partnership with

Dana Farber Cancer Institute/ Pediatric Dana Farber Cancer Institute/ Pediatric Oncology DivisionOncology Division

13 % of patients referred by the Otolaryngology 13 % of patients referred by the Otolaryngology DivisionDivision


Trends in Referral ConcernsTrends in Referral Concerns

Given high volume of VFSS performed we Given high volume of VFSS performed we began to observe trends in subset of patient began to observe trends in subset of patient populationspopulations

Pediatric Oncology Pediatric Oncology Increased incidence in identification and Increased incidence in identification and

diagnosis of the Type 1 laryngeal cleftdiagnosis of the Type 1 laryngeal cleft


Complex Decision MakingComplex Decision Making

Low incidence problems in pediatric dysphagiaLow incidence problems in pediatric dysphagia High stakes for safe and effective management High stakes for safe and effective management

of oropharyngeal dysphagiaof oropharyngeal dysphagia Medical, surgical, ethical and clinical questions Medical, surgical, ethical and clinical questions

we face when treating these childrenwe face when treating these children Highlight the role of the SLP as the preferred Highlight the role of the SLP as the preferred

provider of dysphagia services.provider of dysphagia services.


Pediatric OncologyPediatric Oncology

Patients referred for VFSS with chief complaint Patients referred for VFSS with chief complaint of coughing and choking with thin liquidsof coughing and choking with thin liquids

All patients referred were undergoing All patients referred were undergoing chemotherapy consisting of the drug Vincristine chemotherapy consisting of the drug Vincristine (enrolled in specific treatment protocol for type (enrolled in specific treatment protocol for type of cancer)of cancer)

Onset of symptoms occurred 3-14 days during Onset of symptoms occurred 3-14 days during the treatment of a 6 week cyclethe treatment of a 6 week cycle


Chemotherapy Agent:Chemotherapy Agent:VincristineVincristine

Chemotherapy treats the type of cancer with Chemotherapy treats the type of cancer with medication that is toxic to tumor cells or kills medication that is toxic to tumor cells or kills them through interaction with receptors that them through interaction with receptors that indicate “programmed cell death” or prevent cell indicate “programmed cell death” or prevent cell division.division.

Typically given in cyclesTypically given in cycles Cycle typically lasts 4-6 weeksCycle typically lasts 4-6 weeks Period drug administration- resting periodPeriod drug administration- resting period


Side Effects of Vincristine: Side Effects of Vincristine: NeurotoxicityNeurotoxicity

Involves peripheral, autonomic, and central Involves peripheral, autonomic, and central neuropathyneuropathy

Primary and dose limiting toxicity of VincristinePrimary and dose limiting toxicity of Vincristine Most side effects are dose related and reversibleMost side effects are dose related and reversible Neurotoxicity can persist for months after Neurotoxicity can persist for months after

discontinuation of therapydiscontinuation of therapy Rare cases can be permanently disablingRare cases can be permanently disabling


Results of VFSS in Children Results of VFSS in Children Receiving VincristineReceiving Vincristine

All patients referred were full oral feeders at the All patients referred were full oral feeders at the time of referraltime of referral

All patients undergoing intravenous All patients undergoing intravenous administration of Vincristineadministration of Vincristine

Parents report onset (often sudden) of Parents report onset (often sudden) of sputtering, coughing and choking mainly with sputtering, coughing and choking mainly with liquidsliquids

Attending oncologist referred patient for VFSSAttending oncologist referred patient for VFSS


Results of VFSS in Children Results of VFSS in Children Receiving VincristineReceiving Vincristine

Silent aspiration with thin liquids Silent aspiration with thin liquids Silent aspiration with thin and nectar thick Silent aspiration with thin and nectar thick

liquids liquids Silent aspiration with thin, nectar and honey Silent aspiration with thin, nectar and honey

thick liquidsthick liquids No evidence of aspiration with purees or solidsNo evidence of aspiration with purees or solids


Management of Pharyngeal Dysphagia in Management of Pharyngeal Dysphagia in Children with Vincristine ToxicityChildren with Vincristine Toxicity

Results reported back to Oncology TeamResults reported back to Oncology Team Based on the extent of aspiration modifications Based on the extent of aspiration modifications

to the oral feeding regimen were initiatedto the oral feeding regimen were initiated In cases of aspiration with all liquid In cases of aspiration with all liquid

consistencies discussion regarding non-oral consistencies discussion regarding non-oral supplementation took place with the MD & supplementation took place with the MD & Dysphagia TeamDysphagia Team


Aspiration with Thin Liquid OnlyAspiration with Thin Liquid Only Diet of nectar thick liquidsDiet of nectar thick liquids Recommend referral to nutrition to ensure adequate Recommend referral to nutrition to ensure adequate

hydration and child acceptancehydration and child acceptance Report results to Oncology ClinicReport results to Oncology Clinic Medical team to discuss changes to dose/strength of Medical team to discuss changes to dose/strength of

VincristineVincristine Develop plan for repeat VFSS once team feels Develop plan for repeat VFSS once team feels

neurotoxicity is resolvingneurotoxicity is resolving Parents also report improved clinical status which helps Parents also report improved clinical status which helps

guide timeline for reassessment of swallow functionguide timeline for reassessment of swallow function


Medical ConcernsMedical Concerns

Larger medical concern whether to discontinue cycle of Larger medical concern whether to discontinue cycle of Vincristine to avoid further exacerbation of the toxicity Vincristine to avoid further exacerbation of the toxicity vs. decreasing the dose/strength of the Vincristine.vs. decreasing the dose/strength of the Vincristine.

Child may be made NPO with continuation of Child may be made NPO with continuation of chemotherapy with dose changes.chemotherapy with dose changes.

Child put “on rest” from a swallowing standpoint with Child put “on rest” from a swallowing standpoint with period of going off the drugperiod of going off the drug

Above decision made by attending oncologist with Above decision made by attending oncologist with input from the Oncology-Dysphagia teaminput from the Oncology-Dysphagia team


Medical-Ethical ConsiderationsMedical-Ethical Considerations

Decision to withhold chemotherapy treatment Decision to withhold chemotherapy treatment to allow neurotoxicity to improveto allow neurotoxicity to improve

Parental stressors regarding decisionParental stressors regarding decision Patients taken off Vincristine for # weeks while Patients taken off Vincristine for # weeks while

swallow function improvesswallow function improves Child continues to orally feed with modifications Child continues to orally feed with modifications

in placein place


Resolution of Swallow FunctionResolution of Swallow Function

Swallow function resolved (returned to pre-Vincristine status) in Swallow function resolved (returned to pre-Vincristine status) in 100% of patients.100% of patients.

Range of time it took for swallow function to return to normalRange of time it took for swallow function to return to normal Normal defined as back to full oral diet of thin liquids, purees Normal defined as back to full oral diet of thin liquids, purees

and solidsand solids # of VFSS patients underwent until swallow function resolved. # of VFSS patients underwent until swallow function resolved.

(at what time intervals).(at what time intervals). Recurrence once patient resumed Vincristine treatmentRecurrence once patient resumed Vincristine treatment

Yes in some patientsYes in some patients Even at reduced strength of drug (50% strength). Even at reduced strength of drug (50% strength).

Oncology team was very conservative with re-starting Oncology team was very conservative with re-starting chemotherapy/ altered doses and child monitored closelychemotherapy/ altered doses and child monitored closely


Case Study Case Study Vincristine ToxicityVincristine Toxicity

5/10/04: 5/10/04: 3 ½ year old girl is diagnosed with 3 ½ year old girl is diagnosed with acute lymphoblastic leukemia acute lymphoblastic leukemia (ALL)(ALL)

Immediately begins chemotherapy Immediately begins chemotherapy (including vincristine)(including vincristine)

Throughout 7 months of Throughout 7 months of chemotherapy, pt. is seen frequently in clinic chemotherapy, pt. is seen frequently in clinic for “chronic upper respiratory tract for “chronic upper respiratory tract congestion and persistent coughing”congestion and persistent coughing”



12/27/04: 12/27/04: Diagnosed with pneumonia Diagnosed with pneumonia on chest x-rayon chest x-ray

2/3/05:2/3/05: Pt. referred for initial VFSS by oncology team 9Pt. referred for initial VFSS by oncology team 9months into chemotherapy treatments months into chemotherapy treatments

VFSS revealed silent aspiration with thin liquidsVFSS revealed silent aspiration with thin liquids

Patient safe to continue to receive nectar-thick Patient safe to continue to receive nectar-thick liquids, purees, and chewable solidsliquids, purees, and chewable solids


Case Study:Case Study:Vincristine ToxicityVincristine Toxicity

Insert VFSS # 1 of silent Insert VFSS # 1 of silent aspiration with thin aspiration with thin liquids (2/3/05)liquids (2/3/05)


Case StudyCase StudyVincristine ToxicityVincristine Toxicity

2/4/05: 2/4/05: Vincristine component of chemotherapy is withheld Vincristine component of chemotherapy is withheld

Pt. remained on nectar-thick liquids, purees, solidsPt. remained on nectar-thick liquids, purees, solids

2/28/05: 2/28/05: Repeat VFSS continued to reveal silent aspiration Repeat VFSS continued to reveal silent aspiration with thin liquidswith thin liquids

Recommendation: remain on altered oral dietRecommendation: remain on altered oral diet

4/21/05: 4/21/05: Repeat VFSS revealed normal swallow function with Repeat VFSS revealed normal swallow function with no documentation of aspiration with thin liquidsno documentation of aspiration with thin liquids

Respiratory status stableRespiratory status stable


Case Study:Case Study:Vincristine ToxicityVincristine Toxicity

Insert VFSS of normal Insert VFSS of normal swallow function with no swallow function with no aspiration (4/21/05)aspiration (4/21/05)



4/28/05: 4/28/05: Vincristine resumed (50% strength) Vincristine resumed (50% strength) (Pt. maintained nectar-thick liquid diet)(Pt. maintained nectar-thick liquid diet)

6/20/05:6/20/05: 2 mo. follow-up VFSS revealed silent 2 mo. follow-up VFSS revealed silent aspiration with thin liquidsaspiration with thin liquids

Recommendation: Cont. nectar-thick liquidsRecommendation: Cont. nectar-thick liquids

Pt. continues receiving vincristine Pt. continues receiving vincristine

Pt. was asymptomatic from respiratory Pt. was asymptomatic from respiratory standpoint during this timestandpoint during this time

..


Outcome: Case StudyOutcome: Case StudyVincristine ToxicityVincristine Toxicity

10/1/05:10/1/05: Patient completed course of chemotherapy Patient completed course of chemotherapy (No longer receiving vincristine)(No longer receiving vincristine)

11/3/05:11/3/05: Repeat VFSS was normal with no further Repeat VFSS was normal with no further evidence of aspiration with thin liquids evidence of aspiration with thin liquids

Pt. cleared for full oral diet Pt. cleared for full oral diet

Follow-up: Follow-up: Patient tolerated re-introduction of thin Patient tolerated re-introduction of thin liquids and maintained stable respiratory liquids and maintained stable respiratory statusstatus

Complex Decision Making in Complex Decision Making in Pediatric Dysphagia Part 2Pediatric Dysphagia Part 2

Type 1 Laryngeal CleftType 1 Laryngeal Cleft


What is a Laryngeal Cleft (LC)?What is a Laryngeal Cleft (LC)?

Communication between the posterior larynx Communication between the posterior larynx and esophagusand esophagus

Failure of tracheo-esophageal septum to developFailure of tracheo-esophageal septum to develop


Laryngeal EmbryologyLaryngeal Embryology

Trachea and esophagus share common lumen Trachea and esophagus share common lumen during embryogenesisduring embryogenesis

35th day of gestation35th day of gestation Laryngeal cleft is the failure of the interarytenoid Laryngeal cleft is the failure of the interarytenoid

tissue or cricoid tissue to fuse in the posterior tissue or cricoid tissue to fuse in the posterior midlinemidline


Types of Laryngeal CleftsTypes of Laryngeal Clefts

Four classifications of laryngeal cleftsFour classifications of laryngeal clefts Type 3 and 4 diagnosed on first day of life due Type 3 and 4 diagnosed on first day of life due

to severityto severity Type 1 and 2 diagnosis may take months to Type 1 and 2 diagnosis may take months to

years.years. Type 1 is the focus of our talk today.Type 1 is the focus of our talk today.


Classification of Laryngeal CleftsClassification of Laryngeal Clefts

According to lengthAccording to length Type 1: interarynenoid onlyType 1: interarynenoid only Type 2: partial cricoidType 2: partial cricoid Type 3: complete cricoidType 3: complete cricoid Type 4: extending into tracheaType 4: extending into trachea


Classification of Laryngeal Clefts

Benjamin and Inglis, 1989


Clinical Signs & Symptoms of Clinical Signs & Symptoms of Type 1 Laryngeal CleftType 1 Laryngeal Cleft

Noisy breathingNoisy breathing Inspiratory stridorInspiratory stridor Coughing & choking with feedingsCoughing & choking with feedings Chronic pulmonary infectionsChronic pulmonary infections AspirationAspiration A’s and B’s with feedingsA’s and B’s with feedings CyanosisCyanosis


Differential Diagnosis of Differential Diagnosis of Type 1 LCType 1 LC

VFSS (MBS)VFSS (MBS) FEESFEES Chest x-rayChest x-ray Referral to pediatric Referral to pediatric

Otolaryngologist and Otolaryngologist and PulmonologistPulmonologist

High degree of suspicion High degree of suspicion of type 1 laryngeal cleft of type 1 laryngeal cleft (LC)(LC)

Direct laryngoscopy is Direct laryngoscopy is needed for definitive needed for definitive diagnosis and is the gold diagnosis and is the gold standard for diagnosisstandard for diagnosis


Suspicion of Type 1 LCSuspicion of Type 1 LC

Child presents with normal development with Child presents with normal development with exception of isolated swallowing dysfunctionexception of isolated swallowing dysfunction

No evidence of neurogenic, medical, and genetic No evidence of neurogenic, medical, and genetic etiology for swallow dysfunction. etiology for swallow dysfunction.


Incidence of Laryngeal Clefts Incidence of Laryngeal Clefts (all types)(all types)

Rare, less than 0.1% Rare, less than 0.1% Incidence increases to 0.6% in patients with the Incidence increases to 0.6% in patients with the

co-existence of TEF and laryngeal cleftco-existence of TEF and laryngeal cleft Strong association with other anomalies, but in Strong association with other anomalies, but in

our population has often existed in isolationour population has often existed in isolation (Cotton & Prescott, 1998)(Cotton & Prescott, 1998)


Type 1 LC at Children’s Hospital Type 1 LC at Children’s Hospital BostonBoston

30 patients diagnosed with type 1 laryngeal cleft 30 patients diagnosed with type 1 laryngeal cleft from 2000-2005.from 2000-2005.

21 patients repaired.21 patients repaired. >90% patients with improved swallow function >90% patients with improved swallow function

after repair.after repair.


Incidence on the riseIncidence on the rise

Literature review documents incidence of type 1 Literature review documents incidence of type 1 laryngeal cleft higher than in the past.laryngeal cleft higher than in the past.

7.6% 7.6% (Chien et al, 2006)(Chien et al, 2006)

6.2% 6.2% (Watters & Russell, 2003)(Watters & Russell, 2003)

7.1% 7.1% (Parsons et al, 1998)(Parsons et al, 1998) Are there now more patients with type 1 laryngeal cleft Are there now more patients with type 1 laryngeal cleft

or are we getting better at the diagnosis?or are we getting better at the diagnosis?


Associated Congenital Anomalies Associated Congenital Anomalies with laryngeal cleftwith laryngeal cleft

Pallister-Hall SyndromePallister-Hall Syndrome G SyndromeG Syndrome TEFTEF Esophaeal Atresia and StenosisEsophaeal Atresia and Stenosis


Team Approach to Differential Team Approach to Differential Diagnosis Diagnosis

SLP (pediatric feeding & swallowing specialist)SLP (pediatric feeding & swallowing specialist) Otolaryngologist (ENT)Otolaryngologist (ENT) PulmonologistPulmonologist GastroenterologistGastroenterologist RadiologistRadiologist Developmental PediatricianDevelopmental Pediatrician


Center for Aerodigestive Center for Aerodigestive Disorders (CADD)Disorders (CADD)

Monthly meeting to review complex cases and Monthly meeting to review complex cases and collaborate on differential diagnosiscollaborate on differential diagnosis

Multidisciplinary team approach to diagnosis Multidisciplinary team approach to diagnosis and treatment for aerodigestive casesand treatment for aerodigestive cases

CADD clinic meets 1x per monthCADD clinic meets 1x per month Patients see GI, ORL, Pulmonary and VFSS on Patients see GI, ORL, Pulmonary and VFSS on

same daysame day


Typical course of patient Typical course of patient

VFSS: documentation of aspiration of thin VFSS: documentation of aspiration of thin liquidsliquids

Unable to visualize laryngeal cleft on Unable to visualize laryngeal cleft on fluoroscopyfluoroscopy

Patient placed on treatment of thickened liquidsPatient placed on treatment of thickened liquids PCP referral to Otolaryngologist for further PCP referral to Otolaryngologist for further

assessment assessment


Alternate treatmentsAlternate treatmentsfor Type 1 LCfor Type 1 LC

Identification and management of GERDIdentification and management of GERD Thickened liquidsThickened liquids NG-tube or G-tubeNG-tube or G-tube These treatments may be implemented prior to These treatments may be implemented prior to

surgical repairsurgical repair


Surgical treatment of Type 1 LCSurgical treatment of Type 1 LC

Historically, an invasive surgical procedureHistorically, an invasive surgical procedure Endoscopic procedureEndoscopic procedure Robotic Procedure at Children’s Hospital Robotic Procedure at Children’s Hospital

BostonBoston


Laryngeal CleftLaryngeal Cleft Endoscopic repair Endoscopic repair Laryngeal CleftLaryngeal Cleft Endoscopic repair Endoscopic repair


Timeline from diagnosis to Timeline from diagnosis to recoveryrecovery

VFSSVFSS ORL consultORL consult Direct laryngoscopy Direct laryngoscopy Maintenance dietMaintenance diet RepairRepair Repeat VFSS 6-8 weeks after repairRepeat VFSS 6-8 weeks after repair Full recovery not documented on VFSS until 2-Full recovery not documented on VFSS until 2-

10 months post surgery10 months post surgery

Case Study Case Study Laryngeal CleftLaryngeal Cleft

16-month-old boy with normal growth and 16-month-old boy with normal growth and developmentdevelopment

Admitted to CHB for:Admitted to CHB for:-respiratory distress-respiratory distress-fever of 102-fever of 102°°-perioral cyanosis-perioral cyanosis-mother reports history of 6 episodes of -mother reports history of 6 episodes of

pneumonia in the past 5 months (all LLL)pneumonia in the past 5 months (all LLL)



Videofluoroscopic swallow study performed during Videofluoroscopic swallow study performed during admission:admission:

Revealed:Revealed: silent aspiration with thin liquidssilent aspiration with thin liquids silent aspiration with nectar-thick liquids silent aspiration with nectar-thick liquids Safe to consume honey-thick liquids, purees and chewable Safe to consume honey-thick liquids, purees and chewable

solids orallysolids orally

Recommended nutrition consult to assess hydration needs on Recommended nutrition consult to assess hydration needs on honey-thick liquidshoney-thick liquids


Case Study:Case Study:Laryngeal CleftLaryngeal Cleft

INSERT VFSS HERE INSERT VFSS HERE of pt. aspirating with thin of pt. aspirating with thin and nectar-thick liquidsand nectar-thick liquids



PCP referral to Otolaryngology (ORL)PCP referral to Otolaryngology (ORL) Direct laryngoscopy and bronchoscopy performed Direct laryngoscopy and bronchoscopy performed Type I laryngeal cleft diagnosed.Type I laryngeal cleft diagnosed.

1 month later: endoscopic repair of Type I laryngeal cleft by 1 month later: endoscopic repair of Type I laryngeal cleft by ORL ORL

Sent home after surgery on honey-thick liquids (same pre-Sent home after surgery on honey-thick liquids (same pre-operative diet)operative diet)

Repeat VFSS 4 ½ months s/p repair revealed no aspiration with Repeat VFSS 4 ½ months s/p repair revealed no aspiration with thin and nectar-thick liquids thin and nectar-thick liquids

Patient cleared for unrestricted oral diet Patient cleared for unrestricted oral diet


Summary: Vincristine Toxicity in Summary: Vincristine Toxicity in Pediatric Pharyngeal DysphagiaPediatric Pharyngeal Dysphagia

Low incidence problem but with significant Low incidence problem but with significant consequences for pulmonary health, swallow consequences for pulmonary health, swallow function and treatment decisions.function and treatment decisions.

Increased awareness to respiratory symptoms in Increased awareness to respiratory symptoms in pediatric patients undergoing chemotherapy pediatric patients undergoing chemotherapy treatment.treatment.

Decreased referral time.Decreased referral time. Highlights the importance of the role of the SLP Highlights the importance of the role of the SLP

on the dysphagia-oncology team.on the dysphagia-oncology team.


Complex Decision Making in Pediatric DysphagiaComplex Decision Making in Pediatric Dysphagia

Lowry, Fletcher Larson & Miller, 11-17-06Lowry, Fletcher Larson & Miller, 11-17-06ReferencesReferences

Benjamin B, Inglis A. Minor congenital laryngeal clefts: diagnosis and classification. Ann Otol Rhinol Laryngol Benjamin B, Inglis A. Minor congenital laryngeal clefts: diagnosis and classification. Ann Otol Rhinol Laryngol 1989;98:417-420.1989;98:417-420.

Bermudez, M., Fuster, JL, Llinares, E., Galera, A, Gonzalez, C. Intraconazole-related increased vincristine Bermudez, M., Fuster, JL, Llinares, E., Galera, A, Gonzalez, C. Intraconazole-related increased vincristine neurtoxicity: case report and review of literature, Journal of Pediatric Hematology & Oncology, 2005, July neurtoxicity: case report and review of literature, Journal of Pediatric Hematology & Oncology, 2005, July 27(7): 389-92.27(7): 389-92.

Boseley, Mark et al., The utility of fiberoptic endoscopic evaluation of swallowing (FEES) in diagnosing and Boseley, Mark et al., The utility of fiberoptic endoscopic evaluation of swallowing (FEES) in diagnosing and treating children with Type 1 laryngeal clefts. International Journal of Pediatric Otorhinolaryngology (2006) 70, treating children with Type 1 laryngeal clefts. International Journal of Pediatric Otorhinolaryngology (2006) 70, 339-343.339-343.

Chien, Wade et al., Type 1 laryngeal cleft: Establishing a functional diagnostic and management algorithm, Chien, Wade et al., Type 1 laryngeal cleft: Establishing a functional diagnostic and management algorithm, International Journal of Pediatric Otorhinolaryngology (2006). Article in press.International Journal of Pediatric Otorhinolaryngology (2006). Article in press.

Cotton, R.T. & Prescott, C.A.J. 1998. Congenital anomalies of the larynx. In Cotton, R.T. & Myer, C.M. (eds). Cotton, R.T. & Prescott, C.A.J. 1998. Congenital anomalies of the larynx. In Cotton, R.T. & Myer, C.M. (eds). Prescribed paediatric otolaryngology: 497-513. Philadelphia: Lippincott-Raven.Prescribed paediatric otolaryngology: 497-513. Philadelphia: Lippincott-Raven.

Jeng, MR, Feusner, J. Itraconazole-enhanced vincristine neurotoxicity in a child with acute lymphoblastic Jeng, MR, Feusner, J. Itraconazole-enhanced vincristine neurotoxicity in a child with acute lymphoblastic leukemia. Pediatric Hematology & Oncology. 2001, March: 18 (2): 137-42.leukemia. Pediatric Hematology & Oncology. 2001, March: 18 (2): 137-42.

Langmore, Susan. Evaluation of oropharyngeal dysphagia: which diagnostic tool is superior, Curr. Opin. Langmore, Susan. Evaluation of oropharyngeal dysphagia: which diagnostic tool is superior, Curr. Opin. Otolaryngol. Head Neck Surg. 11 (2003) 485-489.Otolaryngol. Head Neck Surg. 11 (2003) 485-489.

Parsons, D, Stivers, F, Giovaeto, D, Phillips, S. Type1 posterior laryngeal clefts, Laryngoscope 108, March Parsons, D, Stivers, F, Giovaeto, D, Phillips, S. Type1 posterior laryngeal clefts, Laryngoscope 108, March 1998. 403-410.1998. 403-410.

Schulmeister, Lisa, RN, MN, CS, OCN. Preventing Vincristine Sulfate Medication Errors. Oncology Nursing Schulmeister, Lisa, RN, MN, CS, OCN. Preventing Vincristine Sulfate Medication Errors. Oncology Nursing Forum, Volume 3, No. 5, E90-E98.Forum, Volume 3, No. 5, E90-E98.

Watters, K, Russell, J. Diagnosis and management of type 1 laryngeal cleft, Int. J. Pediatric Watters, K, Russell, J. Diagnosis and management of type 1 laryngeal cleft, Int. J. Pediatric Otorhinolaryngology. 67, June 2003. 591-596.Otorhinolaryngology. 67, June 2003. 591-596.

complex decision making in pediatric dysphagia

Documents