title: Neurologic Evaluation in Children With Laryngeal Cleft.
abstract: Referral to a neurologist and imaging play important roles in the management of laryngeal cleft. Swallowing involves a complex series of neuromuscular interactions, and aspiration can result from anatomical causes (eg, laryngeal cleft), neuromuscular disorders, or some combination thereof. To date, no protocols or guidelines exist to identify which patients with laryngeal cleft should undergo neuroimaging studies and/or consultation with a neurologist.
  
  
  
  To establish guidelines for neurologic evaluation and imaging techniques to identify or rule out neuromuscular dysfunction in children with laryngeal cleft.
  
  
  
  Retrospective review of the medical records of 242 patients who were diagnosed with laryngeal cleft at a tertiary children's hospital between March 1, 1998, and July 6, 2015. Based on this review, an algorithm to guide management of laryngeal cleft is proposed.
  
  
  
  Data extracted from patient medical records included the type of laryngeal cleft, details of neurologic referral, results of neuroimaging studies, and objective swallow study outcomes.
  
  
  
  Of the 242 patients, 142 were male and 100 were female. Mean age at the time of data analysis was 8.7 years (range, 10 months to 25 years), and there were 164 type I clefts, 64 type II, 13 type III, and 1 type IV. In all, 86 patients (35.5%) were referred to a neurologist; among these, 33 (38.4%) had examination findings indicative of neuromuscular dysfunction or dyscoordination (eg, hypotonia, spasticity, or weakness). Abnormal findings were identified in 32 of 50 patients (64.0%) who underwent brain imaging. Neurosurgical intervention was necessary in 3 patients diagnosed with Chiari malformation and in 1 patient with an intraventricular tumor detected on neuroimaging.
  
  
  
  A substantial proportion of patients with laryngeal cleft have coexistent neuromuscular dysfunction as a likely contributing factor to dysphagia and aspiration. Collaboration with a neurologist and appropriate neuroimaging may provide diagnostic and prognostic information in this subset of patients. At times, imaging will identify critical congenital malformations that require surgical treatment.
authors.affiliation: Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts.
authors.forename: Ryan D
authors.initials: RD
authors.lastname: Walker
authors.affiliation: Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts.
authors.forename: Alexandria L
authors.initials: AL
authors.lastname: Irace
authors.affiliation: Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts2Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts.
authors.forename: Margaret A
authors.initials: MA
authors.lastname: Kenna
authors.affiliation: Department of Neurology, Boston Children's Hospital, Boston, Massachusetts.
authors.forename: David K
authors.initials: DK
authors.lastname: Urion
authors.affiliation: Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts2Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts.
authors.forename: Reza
authors.initials: R
authors.lastname: Rahbar
mesh_terms: D000293:Adolescent; D000465:Algorithms; D002648:Child; D002675:Child, Preschool; D000013:Congenital Abnormalities / Q000000981:diagnostic imaging* / Q000503:physiopathology*; D005260:Female; D006801:Humans; D007223:Infant; D007830:Larynx / Q000002:abnormalities* / Q000000981:diagnostic imaging / Q000503:physiopathology; D008297:Male; D059906:Neuroimaging; D009460:Neurologic Examination; D012017:Referral and Consultation; D012189:Retrospective Studies; D055815:Young Adult