Clinical Review & Education

JAMA Otolaryngology–Head & Neck Surgery | Review

Diagnosis and Management of Pediatric Dysphagia

A Review
Claire M. Lawlor, MD; Sukgi Choi, MD, MBA

IMPORTANCE Awareness of swallowing dysfunction in the pediatric population is growing.

As many as 50% of parents report that their otherwise healthy children have a feeding
problem. Dysphagia is increasingly common in the pediatric population, especially as
advances in health care improve the survival of extremely premature infants and children
with complex congenital anomalies. Symptoms of dysphagia and aspiration prompt referral
to otolaryngologists.

OBSERVATIONS Dysfunction can exist at any of the 4 phases of the physiologic swallow.
Dysphagia manifests differently in children at each age in their development. Dysphagia
can present in otherwise healthy children but is more common in patients with a history of Author Affiliations: Department of
prematurity, neuromuscular disorders, cardiopulmonary disorders, anatomic anomalies of Otolaryngology, Children’s National
Health System, Washington, DC
the upper aerodigestive tract, and gastrointestinal tract disorders. Workup involves clinical
(Lawlor); Department of
feeding evaluations, imaging studies, and endoscopic evaluations. Appropriate management Otolaryngology & Communication
depends on the cause of dysphagia. Enhancement, Boston Children’s
Hospital, Boston, Massachusetts
CONCLUSIONS AND RELEVANCE The causes of dysphagia in children are varied and often (Choi).
multifactorial. Evaluation by a multidisciplinary team can facilitate accurate diagnosis and Corresponding Author: Sukgi Choi,
guide management. MD, MBA, Department of
Otolaryngology & Communication
Enhancement, Boston Children’s
JAMA Otolaryngol Head Neck Surg. doi:10.1001/jamaoto.2019.3622 Hospital, 300 Longwood Ave
Published online November 27, 2019. BCH3129, Boston, MA 02115 (sukgi.
choi@childrens.harvard.edu).

A
ppropriate nutritional intake is essential for the rapid
growth and development that occurs during infancy and
childhood. 1 Feeding and swallowing dysfunction are
diagnosed with increasing frequency, especially in children with a
history of prematurity, neuromuscular disorders, cardiopulmonary
disorders, anatomic anomalies of the upper aerodigestive tract, and
gastrointestinal tract disorders.2-4 Early diagnosis and intervention
by a multidisciplinary team are essential to the management of
swallowing disorders in children.5
Physiologic Characteristics of Swallowing
The normal swallow is classically divided into 4 phases: the prepa-
ratory phase, the oral phase, the pharyngeal phase, and the
esophageal phase. The preparatory phase is when food is taken
into the oral cavity, moistened with saliva, chewed, and prepared
into a bolus using the oral tongue and hard palate. This phase
develops at approximately age 6 months. Before age 6 months,
the preparatory phase consists of sucking from a nipple. The oral
phase is the propulsion of the food bolus into the oropharynx by
the oral tongue and the triggering of the swallow reflex. The soft
palate elevates to prevent food from regurgitating into the naso-
pharynx. The pharyngeal phase is the passage of the food bolus
through the oropharynx and hypopharynx toward the esophagus
via coordinated muscle contraction. The velum approximates the
pharyngeal musculature, the larynx elevates and the vocal folds
adduct, and the tongue and pharyngeal muscles propel the bolus
into the pharynx.2,5,6 Respiration ceases during the pharyngeal
phase; in fact, while eating, the respiratory rate becomes faster
and more irregular than during tidal breathing.7,8 The esophageal
phase consists of cricopharyngeus relaxation, allowing the food
bolus to enter the esophagus, and coordinated smooth muscle
peristalsis passes the bolus into the stomach.2,9
Development of the suck and swallow begins in utero as
early as gestational week 10 or 11. Gestational age 34 to 38 weeks is
typically when most children develop efficiency and tolerance of
oral feeding.5,10,11 In infants, all 4 phases are under involuntary re-
flex control. In children and adults, the preparatory and oral phases
are under voluntary control, and the pharyngeal and esophageal
phases remain involuntary.2
A physiologic swallow is the result of the complex integration
of more than 30 nerves and muscles and must progress with the
child as their anatomy matures.2 Dysphagia is defined as difficulty
swallowing and must be distinguished from behavioral feeding
disorders, such as oral aversion.1 Dysphagia can be further catego-
rized depending on the disordered phase of swallowing. Oral dys-
phagia can present as absent oral reflexes, immature or absent suck,
uncoordinated biting/chewing, and poor handling of the food
bolus. Pharyngeal dysphagia can present as laryngeal penetration,
when the food bolus enters the laryngeal vestibule; aspiration, when
the food enters the airway below the vocal folds; choking, when food
obstructs the airway; pharyngeal reflux; and nasopharyngeal reflux.1
Esophageal dysphagia results from obstruction of passage of the
food bolus through the esophagus or by poor coordination of esoph-
ageal muscle contractions.

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 Clinical Review & Education Review Diagnosis and Management of Pediatric Dysphagia

Epidemiologic Characteristics
The incidence of pediatric dysphagia is estimated to be 0.9% but Box. Disorders Predisposing Pediatric Patients to Swallowing
is thought to be higher in at-risk populations.2,12,13 As our ability to Dysfunction and Dysphagia
care for patients with extreme prematurity and complex medical
conditions, such as cerebral palsy, bronchopulmonary dysplasia, Structural Abnormalities
Nose and Nasopharynx
and cardiac anomalies improves, the incidence of swallowing dis-
Choanal stenosis or atresia
orders, increases.5 In addition, as many as 50% of parents report
Piriform aperture stenosis
that their otherwise healthy children have feeding problems and
as many as 80% of children with developmental delays may have Congenital intranasal masses
difficulties feeding.4 Midface hypoplasia
Inferior turbinate hypertrophy
Causes of Dysphagia Adenoid hypertrophy
The cause of dysphagia can result from a single medical issue but Nasopharyngeal masses
is commonly multifactorial, resulting from a confluence of comor-
bid conditions. Common causes of swallowing dysfunction can be Oral Cavity and Oropharynx
Oral ties
found in the Box. Determining the cause of dysphagia is vital to
identifying the appropriate intervention. Micrognathia or retrognathia
Cleft lip or palate
Prematurity Macroglossia
Prematurity is a common cause of dysphagia in infants.5,11,14-16 High arched palate
A large, population-based cohort study found the prevalence Congenital oral masses
of feeding problems in premature infants born at less than Tongue base masses
37 weeks’ gestation to be 10.5%, increasing to 24.5% among
those born with a very low birth weight of less than 1500 g.17 Hypopharynx and Larynx
Laryngomalacia
Delay in development of head control, tongue movement,
palatal function, gag reflex, and laryngeal sensation can Vocal fold immobility
contribute to poor swallow. 3 Premature infants often have Laryngotracheoesophageal cleft
comorbid pulmonary and central nervous system disease, further Glottic stenosis
complicating the dysphagia. Abnormalities of the aerodigestive Subglottic stenosis
system, such as laryngomalacia, or iatrogenic injury resulting Laryngeal masses
from respiratory support, such as prolonged intubation or
Vascular malformations
tracheostomy, can further complicate and delay development of a
normal swallow.3,18 Trachea and Esophagus
Esophageal atresia

Neuromuscular Tracheoesophageal fistula

Neuromuscular disorders disrupt the complex coordination Cricopharyngeal achalasia
of sensory and motor functions necessary for a safe swallow. Vascular rings and slings
Delayed reflexes, hypotonia, and generalized discoordination Tracheobronchomalacia
contribute to the dysphagia. The presentation and clinical Tracheal stenosis
course of the dysphagia are determined by the level of the central
nervous system insult and whether it is static or progressive.3 Comorbid Conditions
Prematurity
Conditions that affect the central nervous system can have a sig-
nificant effect on swallow, such as cerebral palsy, congenital viral Neuromuscular
infections, Arnold-Chiari malformation, microcephaly, hydro- Cerebral palsy
cephalus, intraventricular hemorrhage, periventricular leuko- Congenital viral infections
malacia, traumatic brain injury, muscular dystrophies, seizure dis- Arnold-Chiari malformation
orders, and tumors. 1,3,5 Cerebral palsy is the most common Microcephaly
neurologic condition associated with dysphagia in children. 5 Hydrocephalus
Increasing awareness of the relationship between neurologic
Intraventricular hemorrhage
disease and swallow dysfunction has led to increased diagnosis
Periventricular leukomalacia
and earlier intervention.
Traumatic brain injury
Anatomic Abnormalities of the Aerodigestive Tract Muscular dystrophies
Anatomic abnormalities of the upper aerodigestive tract Seizure disorders
can interfere with the complex coordination required for Central nervous system tumors
normal swallow. Common causes can be found in the Box by
(continued)
anatomic subsite and often vary depending on the age of
the patient.2,3,5,19-29

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 Diagnosis and Management of Pediatric Dysphagia
Box. (continued)
Cardiopulmonary
Congenital cardiac disease
Bronchopulmonary dysplasia
Thoracic surgical procedures
Gastrointestinal
Gastroesophageal reflux disease
Eosinophilic esophagitis
Iatrogenic
Prolonged intubation
Need for positive pressure ventilation
Tracheotomy
Prolonged parenteral or enteral tube feeds
Disorders of the Gastrointestinal Tract
Gastroesophageal reflux, or the reflux of gastric contents into the
esophagus with or without regurgitation or vomiting, is physi-
ologic in healthy infants. It is considered pathologic and termed
gastroesophageal reflux disease (GERD) when it is associated with
symptoms or complications.30 The incidence of GERD in North
American infants is estimated to be between 10% and 20%.3
Symptoms of GERD in an infant include irritability, failure to thrive,
feeding refusal, posturing, cough, stridor, and hoarseness. As the
child ages, symptoms may include epigastric pain, dysphagia,
odynophagia, dental erosion, and chest pain. Frequent regurgita-
tion and vomiting are not considered physiologic in older
children.2 GERD can contribute to oropharyngeal dysphagia by re-
ducing the mucosal sensation of the upper aerodigestive tract.3
Eosinophilic esophagitis is another inflammatory condition of
the gastrointestinal tract that can affect swallowing in children.
Eosinophilic esophagitis is an immune-mediated disease linked to
food allergies, genetic predisposition, and environmental factors.31
The mechanism is not entirely understood, but evidence suggests
eosinophilic esophagitis is a T helper cell-2–mediated response to
antigens in food. In the United States, the incidence of eosinophilic
esophagitis in children aged 0 to 4 years ranges from 3.28 to
15.92 per 100 000 per year.32 Children present with vomiting, chok-
ing with meals, dysphagia to both liquids and solids, retrosternal
pain, food impaction, and failure to thrive.3,31 Eosinophilic esopha-
gitis is diagnosed on esophagogastroduodenoscopy with biopsy.
During endoscopy, inflammation and edema of the esophagus are
often visible with loss of vascularity. Within the esophagus, there can
be linear furrows, concentric rings (referred to as trachealization),
and white specks on the mucosa. The diagnosis is confirmed on bi-
opsy sampling, with more than 15 intraepithelial eosinophils per high-
power field being considered diagnostic of eosinophilic
esophagitis.33,34
Cricopharyngeal achalasia is an uncommon cause of dyspha-
gia in young children. Cricopharyngeal achalasia causes pharyngeal
phase dysphagia and presents with coughing, choking, gagging, and
nasal regurgitation. Swallowing liquids may be more difficult for
patients with cricopharyngeal achalasia because of an increased
risk of laryngeal penetration.35 The pathophysiologic characteris-
tic of cricopharyngeal achalasia is a tonically contracted upper
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Review Clinical Review & Education
esophageal sphincter with intermittent relaxation. The disorder is
commonly diagnosed with a modified barium swallow study
that identifies a classic bar in the region of the cricopharyngeus.
Esophageal manometry confirms failure of cricopharyngeal
muscle relaxation.35,36
Cardiopulmonary Disease
Premature and term infants with complex medical conditions, such
as congenital heart disease and bronchopulmonary dysplasia, are
at risk for swallowing dysfunction.1,37,38 The prevalence of dys-
phagia in infants after cardiac repair reportedly ranges from 22%
to 50%.37 The cause of dysphagia associated with cardiac defects
and cardiac surgery is likely multifactorial and may be related to the
abnormal thoracic anatomy; iatrogenic injury, including the recur-
rent laryngeal nerve; need for prolonged intubation, ventilation,
or respiratory support; and the influence of anesthetics and
narcotics.37 Infants with pulmonary disease at birth, including
bronchopulmonary dysplasia, often have difficulty coordinating the
suck-swallow-breathe pattern and are at increased risk for GERD
and other feeding difficulties.39,40 Like cardiac patients, infants with
bronchopulmonary dysplasia may also require prolonged respira-
tory support and alternative sources of nutrition (eg, parenteral
feeds or enteral tube feeds) that delay the development of the nor-
mal swallow. Risks of chronic aspiration and inadequate nutritional
intake are compounded in these chronically ill infants.
Presentation
The presenting symptoms of swallowing dysfunction in children vary
depending on the cause of the dysphagia. Symptoms, such as pro-
longed feeding time, little interest in feeding, or food refusal; postur-
ing, such as back arching and neck extension; failure to thrive;
nasal regurgitation; cough; choking; wet respirations during and af-
ter feeding; and increased work of breathing should prompt a care-
giver to seek evaluation for feeding disorders.41,42 Laryngeal penetra-
tion and aspiration can be present without classic feeding symptoms.
Silent aspiration is the term given to aspiration that occurs without
coughing or attempts to clear the food bolus from the airway. The
laryngeal cough reflex is not stimulated. Silent aspiration is thought
to be related to decreased laryngopharyngeal sensation, neurologic
weakness or incoordination of the pharyngeal musculature, or weak
cough.43 Alternatively, irritation of the airway from the food bolus can
result in cyanosis or brief, resolved unexplained events (formerly called
apparent life-threatening events).44 Aspiration can lead to acute and
chronic respiratory disease in children, including pneumonias and
bronchiectasis.41,43 Children with recurrent respiratory tract infec-
tions without other overt signs of swallowing dysfunction should
undergo a workup for dysphagia.
Evaluation
Evaluation of a child with concern for swallowing dysfunction be-
gins with a thorough history and physical examination performed
by a physician. Often, one of the next steps is referral to a speech
language pathologist (SLP) for further assessment. The evaluation
of children with feeding disorders is not standardized. There are no
validated screening questionnaires for dysphagia in the general pe-
diatric population, although they exist for specific disease cohorts.45
Development of such questionnaires is an area for future study.
An algorithm for the evaluation and management of pediatric
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 Clinical Review & Education Review Diagnosis and Management of Pediatric Dysphagia

Figure 1. Algorithm for Evaluation and Management Figure 2. Image of Fluoroscopic Swallow Study
of Pediatric Dysphagia

Feeding difficulty

Oral aversion, picky Dysphagia

eaters, and other
symptoms

Feeding therapy VFSS or FEES

Oral dysphagia Pharyngeal Esophageal

dysphagia dysphagia

Feeding therapy, Aspiration UGI,

change nipple esophagoscopy

This image demonstrates aspiration or barium-enhanced material in the airway.

No Yes: Chest
radiography
or CT
Medical/surgical
treatment based is introduced and, in other tests, varying consistencies may be
DLB ±
on findings examined.5 The water can be introduced in single sips, consecutive
esophagoscopy sips, or in progressive volume challenges.46 The SLP is often able
to determine whether the dysfunction lies in the preparatory phase,
the oral phase, the pharyngeal phase, or a combination.4 The SLP
No cause identified Cause identified can also determine whether the child is able to participate in and
whether it is safe to proceed with additional swallowing
Neurologic evaluation examinations.5 The bedside swallow is a sufficient screening test for
± brain MRI aspiration; however, it cannot detect silent aspiration.46

Medical management: Surgical management Video Fluoroscopic Swallow Study

thickeners, formula depending on cause vs
change, feeding therapy medical management:
thickeners, formula
change, feeding therapy
Swallow still unsafe
Alternative feeding
access: NGT, GT, GJT
CT indicates computed tomography; DLB, direct laryngoscopy and
bronchoscopy; FEES, functional endoscopic evaluation of swallow;
GJT, gastrojejunostomy tube; GT, gastrostomy tube; MRI, magnetic resonance
imaging; NGT, nasogastric tube; UGI, upper gastrointestinal series; and
VFSS, video fluoroscopic swallow study.
dysphagia is presented in Figure 1. The goals of the following tests
are not only to determine the cause of the dysphagia, but also to
identify a safe means for nutritional intake.3
Clinical Feeding Evaluation
A bedside swallow examination is often one of the first tools used
by an SLP in the evaluation of a child with potential dysphagia. In
this clinical examination, a food bolus is introduced to the patient
and swallowing is observed by the clinician. Sometimes just water
The video fluoroscopic swallow study, also called the modified
barium swallow study, is the most commonly used test to evaluate
patients with dysphagia. Food boluses of varying consistency,
from thin liquids to solids, are impregnated with radiographic dye
and ingested by the patient. Fluoroscopy is performed during
ingestion to evaluate for any penetration or aspiration into the air-
way during swallow of the different consistencies (Figure 2).3,5
The child is positioned as close to their normal feeding position as
possible and all 4 phases of swallow are evaluated with a lateral
radiographic view. This procedure is the only objective measure
that confirms penetration and aspiration.4 This study is limited if
the child is unwilling to take any food per the oral route. Safe swal-
lowing while breastfeeding cannot be evaluated with this
examination.5 The video fluoroscopic swallow study exposes the
patient to radiation; increased time spent obtaining the examina-
tion increases the amount of radiation to the child.
Flexible Endoscopic Evaluation of Swallowing
Flexible endoscopic evaluation of swallowing is an examination
typically performed by both an otolaryngologist and an SLP,
although some SLPs perform this examination alone.3 A flexible
nasopharyngoscope is used to examine the nasopharynx, orophar-
ynx, hypopharynx, supraglottis, and glottis. This test provides the
examiners with a thorough evaluation of the anatomy of the pa-
tient’s upper aerodigestive tract. Food boluses are then introduced

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 Diagnosis and Management of Pediatric Dysphagia
and can be observed penetrating the airway during swallow. Ben-
efits of this examination include the ability to evaluate the breast-
feeding child and the lack of exposure to any radiation. Multiple evalu-
ations of complete swallows can be performed without increased
risk to the patient. Limitations of flexible endoscopic evaluation of
swallowing include tolerance of the nasopharyngoscopy, inability to
view the oral phase of swallow, “white out” during swallow where
tissues contract that may obscure that examination, inability to de-
tect microaspiration, and the subjective nature of the evaluation.1,3-5
Upper Gastrointestinal Tract Series
The upper gastrointestinal tract series is a radiographic study that ex-
amines the esophagus, stomach, and duodenum during swallow of
barium-impregnatedfoodbolus.Thisstudycanbeusedtoevaluatethe
esophagealphaseofswallowaswellastheanatomyofthesestructures.5
Imaging
In children with concerns for recurrent aspiration or pneumonia, chest
radiography may be an important part of the workup. Chest radiog-
raphy may demonstrate evidence of pneumonia or chronic lung dis-
ease secondary to aspiration. Computed tomographic or magnetic
resonance imaging of the head, neck, and/or chest may also be indi-
cated to further evaluate suspected abnormal anatomy and for pre-
operative planning, such as for suspected choanal atresia, microgna-
thia, and vascular anomalies. Computed tomographic imaging of the
chest can also demonstrate long-term sequelae of chronic aspira-
tion, including bronchiectasis, air trapping, and bronchial thickening.3
Endoscopic Evaluations
Direct laryngoscopy, bronchoscopy, and esophagoscopies are
important to the complete evaluation of a patient with pharyngeal or
esophageal dysphagia and suspected penetration and/or aspiration.
Endoscopies may not be indicated in isolated oral dysphagia. The
examinations can often be performed during the same procedure in
the operating room with coordination by the otolaryngology, pulmo-
nology, and gastroenterology teams. Endoscopic evaluation pro-
vides the clinicians with an unparalleled examination of the patient’s
anatomy. Direct laryngoscopy allows the otolaryngologist to assess
for anatomic anomalies of the oral cavity, oropharynx, hypopharynx,
supraglottis, glottis, and subglottis. Airway disorders, such as vallecu-
lar cyst, laryngomalacia, vocal fold immobility, and laryngotracheo-
esophageal cleft, can be diagnosed.24-27 Tracheoscopy can diagnose
tracheomalacia, tracheal stenosis, and tracheoesophageal fistula.29
Bronchoscopymayassessforbronchomalacia,bronchiectasis,andevi-
dence of chronic aspiration and pneumonias. Additional testing, such
as biopsies, bronchial washing, pepsin, and lipid-laden macrophage
indices, can supplement the endoscopy.47-49 Esophagoscopy af-
fords an examination of the esophagus and, sometimes, distal struc-
tures, including the stomach and duodenum. Extrinsic compression
and mucosal changes can be visualized. Biopsies may be performed
to evaluate for eosinophilic esophagitis and complications of GERD.30
A multichannel, intraluminal impedance probe may be placed to
assess for acid and nonacid reflux.2
Medical Management
Children with dysphagia benefit from the care of a multidisci-
plinary team that specializes in pediatric swallowing disorders. This
team may consist of pediatricians, developmental pediatricians,
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Review Clinical Review & Education
neurologists, otolaryngologists, pulmonologists, gastroenterolo-
gists, dieticians, and SLPs.2,4 Neurologic evaluation is especially
important in children with dysphagia when no other abnormalities
are found on comprehensive workup, including endoscopies. As with
most pediatric illnesses, the caregiver is an important member of the
treatment team. The key to successful management of dysphagia
is correctly identifying the cause.3
Feeding therapy, performed by an experienced SLP, is often the
first-line treatment for infants and children with dysphagia. This
therapy may consist of altering the means of food delivery, includ-
ing the nipple flow or spoon, changing the feeding position, or pac-
ing the feeds in attempt to improve the suck-swallow-breathe
sequence.2,5,41 Sensory and motor exercises, also implemented by
a trained SLP, improve strength, movement, and coordination of the
lips, tongue, jaw, soft palate, and pharyngeal muscles.4 Feeding
therapy should be attempted only if the child is deemed safe to
receive a trial of oral intake.
Different formulas may also be used in a trial to assess if they
are better tolerated by the patient.3 If a child is able to take some
oral feeds, increasing the caloric value of feeds may improve
nutrition.4 Consulting a pediatric dietician may be necessary to
ensure adequate nutritional intake. If changing the formula is not
successful, the consistencies of the food bolus may need to be
thickened. Thickened feeds may help to reduce or resolve laryn-
geal penetration, aspiration, and GERD. Thickeners have also been
shown to change the swallowing mechanics and improve pacing
during feeds by slowing bolus transit and improving bolus cohe-
sion during swallow.50 A variety of thickeners exist, including rice
cereals, carob bean, and xanthum gum thickeners are on the mar-
ket and must be chosen carefully based on the patient’s age and
comorbidities.2,50 Reflux regimens, including proton pump inhibi-
tors and histamine H2 receptor antagonists are often prescribed
based on clinical symptoms of GERD. The use of acid suppression
in children is controversial and may be associated with increased
hospitalizations. Many symptoms of dysphagia overlap with those
of GERD, resulting in inappropriate implementation of
pharmacotherapy.51,52 With time and conservative management,
many infants with aspiration will improve within 1 to 2 years.53
Surgical Management
Surgical management of dysphagia in children is indicated when an
anatomic abnormality is identified as the cause of the dysphagia. We
will focus on a few common causes relevant to the otolaryngologist.
Ankyloglossia
Ankyloglossia is an area of great interest and controversy within the
feeding literature. Ankyloglossia has been identified as a cause of
shallow latch, poor oral seal, and maternal nipple pain.20 Fre-
notomy is the division in the lingual frenulum. A variety of tech-
niques have been described, the simplest of which involves using
a scissor to incise the frenulum without anesthesia, cautery, or
sutures in young infants. Frenotomy improves feeding in many pa-
tients with ankyloglossia and restricted tongue range of motion. It
is generally a low-risk procedure, with infrequent complications in-
cluding bleeding, infection, injury to the salivary ducts, and need for
revision. However, there is growing concern that ankyloglossia is
overdiagnosed and treated. A tight lingual frenulum is often iden-
tified as the cause of difficulty with breastfeeding, when in fact the
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 Clinical Review & Education Review Diagnosis and Management of Pediatric Dysphagia

Figure 3. Repair of a Type 2 Laryngeal Cleft

A Type 2 cleft before repair B After carbon dioxide laser treatment

Microsuspension laryngoscopy with

carbon dioxide laser and suture
repair. A, Type 2 cleft before repair.
B, After carbon dioxide laser was
used to denude mucosa and suture
closure performed.

Figure 4. Injection Medialization Laryngoplasty (IML) in an Immobile Left Vocal Fold

A Before IML B After IML

A, Before IML. B, After IML; note

that the left vocal fold is slightly
overmedialized to correct for
resorption.

difficulty is often multifactorial, relating to mandible position, ma-
ternal nipple, oral coordination, and other factors.20,54,55 Pub-
lished data on frenotomy are limited by poor standardization of
diagnosis of ankyloglossia and lack of validated outcomes. To our
knowledge, there is no literature to support the surgical manage-
ment of other oral ties, such as upper lip, lower lip, or lateral ties.20
toplasty has been shown to improve swallow outcomes in children
with laryngomalacia.56-59 However, supraglottoplasty can result in
new-onset aspiration in patients without previous swallow
dysfunction.60,61 Children with baseline neurologic dysfunction
and a history of prematurity have an increased risk of aspiration
following supraglottoplasty.62,63

Laryngomalacia Laryngeal Cleft

Swallowing dysfunction associated with laryngomalacia is likely mul-
tifactorial. The incidence of dysphagia in patients with laryngoma-
lacia has been reported to be as high as 50% to 86%, independent
of other medical comorbidities.56-59 The disability may be related
to the diminished sensation and neuromuscular tone of the phar-
ynx and larynx innate to laryngomalacia. The increased work of
breathing during feeding imposed by the anatomically constricted
larynx also interferes with the normal suck-swallow-breathe
sequence. Supraglottoplasty is a microlaryngeal procedure that
divides the aryepiglottic folds and/or removes redundant supra-
arytenoid tissue using cold steel, laser, or microdebrider. Supraglot-
Laryngeal cleft is another area of significant study and controversy
in the otolaryngology literature. Laryngeal cleft is divided into
4 degrees of interarytenoid cleft: type 1 extends to the level of the vo-
cal folds, type 2 extends below the vocal folds and into the cricoid
cartilage, type 3 extends into the cervical trachea, and type 4 ex-
tends into the thoracic trachea. It is widely accepted that cleft types
2 to 4 are anatomic abnormalities and should be repaired.64,65 The
controversysurroundsthediagnosisoftype1laryngealcleftsandwhen
and how to intervene. Laryngeal cleft is diagnosed on direct laryn-
goscopy with palpation of the interarytenoid groove.64 A deep inter-
arytenoid groove to the level of the vocal folds can be identified in

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 Diagnosis and Management of Pediatric Dysphagia Review Clinical Review & Education

patients without swallowing dysfunction when direct laryngoscopy
is performed for other indications, so the anatomic finding alone is
not a reason to intervene. In patients with type 1 laryngeal cleft and
dysphagia or aspiration, most surgeons advocate for a period of
conservative medical management with thickened feeds ranging
from 3 to 12 months.66 Surgical repair of type 1 laryngeal clefts con-
sists of interarytenoid injection augmentation with a filler agent
(carboxymethylcellulose, fat, hyaluronic acid, gelfoam) or inter-
arytenoid suture repair with sharp dissection or the use of laser
(Figure 3).64,66,67 Both procedures are performed endoscopically via
suspension microlaryngoscopy. Injection and suture repair have
both resulted in improved swallow outcomes in children with type 1
laryngeal cleft, although dysphagia and aspiration can persist, espe-
cially if the cause was initially multifactorial.64,65,67 Type 2 laryngeal
clefts are typically approached endoscopically. Types 3 and 4 laryn-
geal clefts are classically repaired via an open approach, although type
3 clefts have been repaired successfully using endoscopes.68
Vocal Fold Immobility
Vocal fold immobility in infants and children can be congenital or ac-
quired. The restricted mobility of 1 or both vocal cords can result in
insufficient cough, glottic incompetence, and frank or silent
aspiration.26,69 However, not all children with unilateral or bilateral
vocal fold immobility have an unsafe swallow. In addition, depend-
ing on the cause, varying degrees of vocal fold function may re-
cover as late as 18 months after injury.69
When both swallowing dysfunction and vocal fold immobility
are diagnosed, intervention is indicated. Surgical approaches to
vocal fold immobility include injection medialization laryngo-
plasty, thyroplasty, and reinnervation procedures.70,71 Proper
procedural selection is based on the patient’s age, prognosis
for recovery of vocal fold function, and the overall patient condi-
tion. The most common procedure performed for dysphagia
and vocal fold immobility is injection medialization laryngoplasty
(Figure 4), which is approached via suspension microlaryn-
goscopy. Common injectates include carboxymethylcellulose,
calcium hydroxyapatite, micronized acellular dermis, and
hyaluronic acid; each has a variable duration of benefit. 70,71
The site of injection is the junction of the medial third and the
posterior third of the vocal fold. The injectate is applied within
the paraglottic space and the vocal fold is overmedialized by
approximately 20% to account for resorption. Early injection
seems to result in greater benefit to the patient.71 In one study,
injection medialization laryngoplasty resulted in objective
improvement in swallow in over 60% of the patients and allowed
for liberalization of diet.69
Conclusions
Dysphagia is an increasingly common disorder in pediatric
patients, especially as advances in health care increase the sur-
vival of premature and medically complex children. The causes of
dysphagia are varied and often multifactorial. Evaluation by a
multidisciplinary team can facilitate accurate diagnosis and guide
management.

ARTICLE INFORMATION
Accepted for Publication: October 6, 2019.
Published Online: November 27, 2019.
doi:10.1001/jamaoto.2019.3622
Author Contributions: Dr Choi had full access to all
of the data in the study and takes responsibility for
the integrity of the data and the accuracy of the
data analysis.
Concept and design: Both authors.
Acquisition, analysis, or interpretation of data:
Lawlor.
Drafting of the manuscript: Lawlor.
Critical revision of the manuscript for important
intellectual content: Both authors.
Supervision: Choi.
Conflict of Interest Disclosures: No disclosures
were reported.
Disclaimer: Dr Choi is a deputy editor of JAMA
Otolaryngology–Head & Neck Surgery, but she was
not involved in any of the decisions regarding
review of the manuscript or its acceptance.
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