4205990 powerpoint

Complex Decision Complex Decision Making in Making in Pediatric 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-SLPChildren’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]

Alana Lowry, MS, CCC-SLPAlana Lowry, MS, CCC-SLP [email protected]

Jennifer Miller, MS, CCC-SLPJennifer Miller, MS, CCC-SLP [email protected]

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Incidence of Pediatric Incidence of Pediatric DysphagiaDysphagia

25% in all children25% in all children 80% in children with developmental 80% in children with developmental

disabilitiesdisabilities 3-10% of children exhibit severe feeding 3-10% of children exhibit severe feeding

problemsproblems Occur with greater prevalence in Occur with greater prevalence in

children with physical disabilities, children with physical disabilities, medical illness and prematuritymedical illness and prematurity

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

newsletternewsletter


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 2005 performed 864 pediatric

videofluoroscopic swallow studiesvideofluoroscopic swallow studies Range in ages from 38 weeks PMA- Range in ages from 38 weeks PMA-

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


Patient DemographicsPatient Demographics

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

6 % of patients referred from Level 3 6 % of patients referred from Level 3 NICUNICU

4 % of patients referred by 4 % of patients referred by partnership with Dana Farber Cancer partnership with Dana Farber Cancer Institute/ Pediatric Oncology DivisionInstitute/ Pediatric Oncology Division

13 % of patients referred by the 13 % of patients referred by the Otolaryngology DivisionOtolaryngology Division


Trends in Referral Trends in Referral ConcernsConcerns

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

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

and diagnosis of the Type 1 and diagnosis of the Type 1 laryngeal cleftlaryngeal cleft


Complex Decision Complex Decision MakingMaking

Low incidence problems in pediatric Low incidence problems in pediatric dysphagiadysphagia

High stakes for safe and effective High stakes for safe and effective management of oropharyngeal dysphagiamanagement of oropharyngeal dysphagia

Medical, surgical, ethical and clinical Medical, surgical, ethical and clinical questions we face when treating these questions we face when treating these childrenchildren

Highlight the role of the SLP as the Highlight the role of the SLP as the preferred provider of dysphagia services.preferred provider of dysphagia services.


Pediatric OncologyPediatric Oncology

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

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

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


Chemotherapy Agent:Chemotherapy Agent:VincristineVincristine

Chemotherapy treats the type of cancer Chemotherapy treats the type of cancer with medication that is toxic to tumor with medication that is toxic to tumor cells or kills them through interaction cells or kills them through interaction with receptors that indicate with receptors that indicate “programmed cell death” or prevent cell “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 Period drug administration- resting

periodperiod


Side Effects of Vincristine: Side Effects of Vincristine: NeurotoxicityNeurotoxicity

Involves peripheral, autonomic, and Involves peripheral, autonomic, and central neuropathycentral neuropathy

Primary and dose limiting toxicity of Primary and dose limiting toxicity of VincristineVincristine

Most side effects are dose related and Most side effects are dose related and reversiblereversible

Neurotoxicity can persist for months Neurotoxicity can persist for months after discontinuation of therapyafter discontinuation of therapy

Rare cases can be permanently Rare cases can be permanently disablingdisabling


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

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

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

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

Attending oncologist referred Attending oncologist referred patient for VFSSpatient 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 Silent aspiration with thin and

nectar thick liquids nectar thick liquids Silent aspiration with thin, nectar Silent aspiration with thin, nectar

and honey thick liquidsand honey thick liquids No evidence of aspiration with No evidence of aspiration with

purees or solidspurees or solids


Management of Pharyngeal Management of Pharyngeal Dysphagia in Children with Dysphagia in Children with

Vincristine ToxicityVincristine Toxicity Results reported back to Oncology Results reported back to Oncology

TeamTeam Based on the extent of aspiration Based on the extent of aspiration

modifications to the oral feeding modifications to the oral feeding regimen were initiatedregimen were initiated

In cases of aspiration with all liquid In cases of aspiration with all liquid consistencies discussion regarding consistencies discussion regarding non-oral supplementation took place non-oral supplementation took place with the MD & Dysphagia Teamwith the MD & Dysphagia Team


Aspiration with Thin Aspiration with Thin Liquid OnlyLiquid Only

Diet of nectar thick liquidsDiet of nectar thick liquids Recommend referral to nutrition to Recommend referral to nutrition to

ensure adequate hydration and child ensure adequate hydration and child acceptanceacceptance

Report results to Oncology ClinicReport results to Oncology Clinic Medical team to discuss changes to Medical team to discuss changes to

dose/strength of Vincristinedose/strength of Vincristine Develop plan for repeat VFSS once team Develop plan for repeat VFSS once team

feels neurotoxicity is resolvingfeels neurotoxicity is resolving Parents also report improved clinical Parents also report improved clinical

status which helps guide timeline for status which helps guide timeline for reassessment of swallow functionreassessment of swallow function


Medical ConcernsMedical Concerns

Larger medical concern whether to Larger medical concern whether to discontinue cycle of Vincristine to avoid discontinue cycle of Vincristine to avoid further exacerbation of the toxicity vs. further exacerbation of the toxicity vs. decreasing the dose/strength of the decreasing the dose/strength of the Vincristine.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 Child put “on rest” from a swallowing standpoint with period of going off the drugstandpoint with period of going off the drug

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


Medical-Ethical Medical-Ethical ConsiderationsConsiderations

Decision to withhold chemotherapy Decision to withhold chemotherapy treatment to allow neurotoxicity to treatment to allow neurotoxicity to improveimprove

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

weeks while swallow function weeks while swallow function improvesimproves

Child continues to orally feed with Child continues to orally feed with modifications in placemodifications in place


Resolution of Swallow Resolution of Swallow FunctionFunction

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

Range of time it took for swallow function to return to Range of time it took for swallow function to return to normalnormal

Normal defined as back to full oral diet of thin liquids, Normal defined as back to full oral diet of thin liquids, purees and solidspurees and solids

# of VFSS patients underwent until swallow function # of VFSS patients underwent until swallow function resolved. (at what time intervals).resolved. (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 chemotherapy, pt. is seen

frequently in clinic frequently in clinic for “chronic upper for “chronic upper respiratory tract respiratory tract congestion and congestion and persistent coughing”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 Pt. referred for initial VFSS by oncology team 9team 9 months into chemotherapy months into chemotherapy treatments treatments

VFSS revealed silent aspiration with VFSS revealed silent aspiration with thin liquidsthin liquids

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


Case Study:Case Study:Vincristine ToxicityVincristine Toxicity

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


Case StudyCase StudyVincristine ToxicityVincristine Toxicity

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

Pt. remained on nectar-thick liquids, purees, Pt. remained on nectar-thick liquids, purees, solidssolids

2/28/05: 2/28/05: Repeat VFSS continued to reveal silent Repeat VFSS continued to reveal silent aspiration 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 Repeat VFSS revealed normal swallow function with 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 Insert VFSS of normal swallow normal swallow function with no function with no aspiration aspiration (4/21/05)(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 Patient completed course of chemotherapy chemotherapy (No longer receiving vincristine)(No longer receiving vincristine)

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

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

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

Complex Decision Making Complex Decision Making in Pediatric Dysphagia in Pediatric Dysphagia

Part 2Part 2

Type 1 Laryngeal CleftType 1 Laryngeal Cleft


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

Communication between the Communication between the posterior larynx and esophagusposterior larynx and esophagus

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


Laryngeal EmbryologyLaryngeal Embryology

Trachea and esophagus share Trachea and esophagus share common lumen during common lumen during embryogenesisembryogenesis

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

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


Types of Laryngeal CleftsTypes of Laryngeal Clefts

Four classifications of laryngeal Four classifications of laryngeal cleftsclefts

Type 3 and 4 diagnosed on first day Type 3 and 4 diagnosed on first day of life due to severityof life due to severity

Type 1 and 2 diagnosis may take Type 1 and 2 diagnosis may take months to years.months to years.

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


Classification of Classification of Laryngeal CleftsLaryngeal 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 & Clinical Signs & Symptoms of Type 1 Symptoms of Type 1

Laryngeal CleftLaryngeal 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 Referral to

pediatric pediatric Otolaryngologist Otolaryngologist and Pulmonologistand Pulmonologist

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

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


Suspicion of Type 1 LCSuspicion of Type 1 LC

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

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


Incidence of Laryngeal Incidence of Laryngeal Clefts Clefts

(all types)(all types) Rare, less than 0.1% Rare, less than 0.1% Incidence increases to 0.6% in Incidence increases to 0.6% in

patients with the co-existence of TEF patients with the co-existence of TEF and laryngeal cleftand laryngeal cleft

Strong association with other Strong association with other anomalies, but in our population has anomalies, but in our population has often existed in isolationoften existed in isolation

(Cotton & Prescott, 1998)(Cotton & Prescott, 1998)


Type 1 LC at Children’s Type 1 LC at Children’s Hospital BostonHospital Boston

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

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

swallow function after repair.swallow function after repair.


Incidence on the riseIncidence on the rise Literature review documents incidence of Literature review documents incidence of

type 1 laryngeal cleft higher than in the type 1 laryngeal cleft higher than in the past.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 Are there now more patients with type 1

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


Associated Congenital Associated Congenital Anomalies with laryngeal Anomalies with laryngeal

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


Team Approach to Team Approach to Differential Diagnosis Differential Diagnosis

SLP (pediatric feeding & swallowing SLP (pediatric feeding & swallowing specialist)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 Monthly meeting to review complex cases and collaborate on differential cases and collaborate on differential diagnosisdiagnosis

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

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

VFSS on same dayVFSS on same day


Typical course of patient Typical course of patient

VFSS: documentation of aspiration VFSS: documentation of aspiration of thin liquidsof thin liquids

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

Patient placed on treatment of Patient placed on treatment of thickened liquidsthickened liquids

PCP referral to Otolaryngologist for PCP referral to Otolaryngologist for further assessment further assessment


Alternate treatmentsAlternate treatmentsfor Type 1 LCfor Type 1 LC

Identification and management of Identification and management of GERDGERD

Thickened liquidsThickened liquids NG-tube or G-tubeNG-tube or G-tube These treatments may be These treatments may be

implemented prior to surgical repairimplemented prior to surgical repair


Surgical treatment of Surgical treatment of Type 1 LCType 1 LC

Historically, an invasive surgical Historically, an invasive surgical procedureprocedure

Endoscopic procedureEndoscopic procedure Robotic Procedure at Children’s Robotic Procedure at Children’s

Hospital BostonHospital Boston


Laryngeal Laryngeal CleftCleft Endoscopic Endoscopic repairrepair

Laryngeal Laryngeal CleftCleft Endoscopic Endoscopic repairrepair


Timeline from diagnosis Timeline from diagnosis to recoveryto recovery

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 Full recovery not documented on

VFSS until 2-10 months post surgeryVFSS until 2-10 months post surgery

Case Study Case Study Laryngeal CleftLaryngeal Cleft

16-month-old boy with normal growth 16-month-old boy with normal growth and developmentand development

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 -mother reports history of 6

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



Videofluoroscopic swallow study Videofluoroscopic swallow study performed during admission:performed during 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 Safe to consume honey-thick liquids, purees

and chewable solids orallyand chewable solids orally

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


Case Study:Case Study:Laryngeal CleftLaryngeal Cleft

INSERT VFSS INSERT VFSS HERE of pt. HERE of pt. aspirating with aspirating with thin and nectar-thin and nectar-thick liquidsthick 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 1 month later: endoscopic repair of Type I laryngeal cleft by ORL cleft by ORL

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

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

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


Summary: Vincristine Summary: Vincristine Toxicity in Pediatric Toxicity in Pediatric

Pharyngeal DysphagiaPharyngeal Dysphagia Low incidence problem but with Low incidence problem but with

significant consequences for pulmonary significant consequences for pulmonary health, swallow function and treatment health, swallow function and treatment decisions.decisions.

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

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

the SLP on the dysphagia-oncology team.the SLP 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. Benjamin B, Inglis A. Minor congenital laryngeal clefts: diagnosis and classification. Ann Otol Rhinol Laryngol 1989;98:417-420.Ann Otol Rhinol Laryngol 1989;98:417-420.

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

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

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

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

Jeng, MR, Feusner, J. Itraconazole-enhanced vincristine neurotoxicity in a child with Jeng, MR, Feusner, J. Itraconazole-enhanced vincristine neurotoxicity in a child with acute lymphoblastic leukemia. Pediatric Hematology & Oncology. 2001, March: 18 (2): acute lymphoblastic leukemia. Pediatric Hematology & Oncology. 2001, March: 18 (2): 137-42.137-42.

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

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

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

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

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