Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences; Children's Hospital Association; Department of Pediatrics, Section of Pediatric Cardiology, University of Arkansas for Medical Sciences
Objective: To determine what factors are associated with overall mortality among pediatric patients with bilateral vocal fold dysfunction. Secondary objective is to characterize bilateral vocal fold dysfunction based on relevant clinical factors such as readmission rate, imaging utilization, and cost of care.
Method: Retrospective cohort analysis was completed using the Pediatric Health Information System database. All pediatric patients with a diagnosis of bilateral vocal fold dysfunction were queried between January 2008 to September 2020 utilizing appropriate ICD-9 and ICD-10 codes. Kaplan-Meier univariate and multivariate analyses were performed.
Results: 2395 patients were identified from 4799 hospitalization encounters. Median length of stay was 26 days and median admission age was 3 months old. There were 69 (2.9%) mortalities. Magnetic resonance imaging was utilized in 16.9% of patients. Chiari malformations were identified in 8.5% of patients. Chiari 2 was found in 2.8% of patients. The most common associated diagnoses were related to comorbid respiratory conditions (61.1%). The median adjusted ratio of cost to charges was $76,569. Aspiration was noted in 28 patients (1.2%). Gastrostomy was performed in 607 patients (25.3%). Tracheostomy was performed in 27% of patients. Gastrostomy tube placement occurred more frequently in patients that had a tracheostomy (54.3% vs. 14.5%, p<0.001). Patients with tracheostomies had longer median mechanical ventilation days (26 vs. 9 days, p<0.001), longer median length of stay (71 vs. 13 days, p<0.001), and higher median adjusted cost ($263,998 vs. $38,327, p<0.001) compared to those without tracheostomies. The overall 90-day readmission rate was 61%. On multivariate analysis, prognostic factors associated with decreased survival included gastrointestinal comorbidities (hazard ratio [HR]: 0.29; 95% confidence interval [CI]: 0.18-0.49) and tracheostomy (HR: 0.21; 95% CI: 0.12-0.37).
Conclusion: This database study represents the largest cohort analysis to date characterizing pediatric bilateral vocal fold dysfunction. Poor prognostic indicators of survival include gastrointestinal comorbidities and presence of tracheostomy. Tracheostomy is associated with an increase in morbidity and mortality, hospital costs, and gastrostomy tube placement.