Vocal cord paralysis in children 1 year of age and younger

Iatrogenic pediatric unilateral vocal cord paralysis after cardiac surgery: a review

Unilateral vocal cord paralysis (UVCP) is a growing area of research in pediatrics as it spans across many specialties including otolaryngology, cardiology, general surgery, respirology, and speech language pathology. Iatrogenic injury is the most common cause of UVCP, however there is a wide range of data reporting the prevalence, symptom burden, and best treatment practice for this condition. The literature included systematic reviews and meta-analyses, retrospective studies and limited prospective studies. Overall, the literature lacked consistency in the diagnosis, treatment, and long-term outcomes of patients with UVCP. Many articles conflated bilateral vocal cord paralysis (BVCP) with UVCP and had limited data on the natural history of the condition. There was no consensus on objective and subjective measurements to evaluate the condition or best indications for requiring surgical intervention. Thyroplasty, injection medialization (IM) and recurrent laryngeal nerve reinnervation (RLNR) were the reported surgical interventions used to treat UVCP, however there was limited data on short and long-term surgical outcomes in children. More research is needed to determine the true prevalence, natural history, indications for surgical intervention and long-term outcomes for pediatric patients with this condition.

Long-term Results of Endoscopic Percutaneous Suture Lateralization for Newborns with Bilateral Vocal Cord Paralysis

PURPOSE

Bilateral vocal fold paralysis (BVFP) is a critical condition in newborns, which may present with significant airway distress necessitating tracheostomy. The purpose of this study is to report the safety and effectiveness of endoscopic percutaneous suture lateralization (EPSL) for newborns with BVFP, and evaluated the long-term results and the stability of the lateralization.

METHODS

A review of patients undergoing EPSL for BVFP at our institutions was performed between October 2018 and June 2023. Preoperative and postoperative clinical information was collected. The functional outcomes of the surgery in terms of breathing, voice, and swallowing were evaluated and recorded.

RESULTS

Twenty seven patients were included, with a median age at diagnosis of 12 days (range, 1-33 days). The maximum follow-up is for 5 years. EPSL was successful in 77.8% of cases, effectively avoiding the need for tracheostomy. Dyspnea was relieved within a month after surgery, enabling patients to tolerate oral feeds within 2 months after surgery. Notably, some patients experienced a return of vocal fold function, particularly in successful EPSL cases, underlining the procedure's efficacy. Minor complications, including granulation tissue and wound infection, were observed but were manageable. Major complications were notably absent. The results are durable and stable at long-term follow-up.

CONCLUSION

EPSL for BVFP is a relatively simple, minimally invasive, non-destructive, safe, and effective procedure in newborns, which may avoid the need for a tracheostomy, preserves the laryngeal framework, and does not affect the natural recovery of vocal cords.

LEVEL OF EVIDENCE

Level 3: retrospective case series Laryngoscope, 2024.

Pediatric Bilateral Vocal Cord Immobility: New Treatment With Preservation of Voice

OBJECTIVES

Pediatric bilateral vocal cord immobility (BVCI) represents a severe life-threatening condition that often causes severe dyspnea. Endoscopic arytenoid lateral abduction (EALA) is a relatively new, secure, minimal-invasive surgical technique. The present prospective observational study aims to evaluate the effects of EALA in terms of respiratory function, voice quality, and swallowing capabilities.

METHODS

Twenty-one pediatric patients with BVCI underwent EALA. Eleven out of 21 patients had tracheostomy at the time of surgery. Pre and postoperative functional assessments included endoscopic evaluation, maximum phonation time, pediatric Voice Handicap Index (pVHI), GIRBAS Scale criteria, and Montreal Children's Hospital Feeding scale (MCH-Feeding scale). peak tidal inspiratory flow or peak inspiratory flow (PIF) and number of desaturations/hour (ODI/h) were evaluated in patients without tracheostomy.

RESULTS

Postoperative endoscopy showed glottic airway improvement in all patients. Average time for decannulation was 4.6 weeks. One patient has not yet been decannulated. No major complications occurred. In patients without tracheostomy, we observed a significant improvement of ODI/h and PIF after surgery (p < 0.05) as expected. PVHI, MCH-Feeding scale, and GIRBAS score significantly worsened 1 month after surgical intervention (p < 0.05). One year after surgery, however, all values, except for B and A parameters of the GIRBAS score, returned to levels comparable to those preoperative.

CONCLUSIONS

EALA represents a simple, safe and effective solution in pediatric patients with BVCI, avoiding tracheostomy, allowing early decannulation, preserving swallowing function, and maintaining good quality voice.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:2325-2332, 2023.

Rare Diseases of Larynx, Trachea and Thyroid

This review article covers data on rare diseases of the larynx, the trachea and the thyroid. In particular, congenital malformations, rare manifestations of inflammatory laryngeal disorders, benign and malignant epithelial as well as non-epithelial tumors, laryngeal and tracheal manifestations of general diseases and, finally, thyroid disorders are discussed. The individual chapters contain an overview of the data situation in the literature, the clinical appearance of each disorder, important key points for diagnosis and therapy and a statement on the prognosis of the disease. Finally, the authors indicate on study registers and self-help groups.

A Review of Treatment of Bilateral Vocal Fold Movement Impairment

Purpose of Review

Bilateral vocal fold immobility is a challenging life-threatening problem involving multiple treatment options and nuanced clinical decision making. We aim to provide relevant background on the etiology, diagnosis, and management of bilateral vocal fold movement impairment (BVFMI).

Recent Findings

Over the last 20 years, the management of bilateral vocal fold immobility has advanced significantly with the addition of multiple endoscopic approaches as well as procedures with the goal of returning dynamic function to the larynx, among them: selective reinnervation. Chemodenervation has also demonstrated promising results as a temporizing procedure in appropriately selected patients with BVFMI.

Summary

Tracheostomy remains the mainstay of emergent treatment for airway obstruction secondary to bilateral vocal fold immobility. However, recent advances in endoscopic approaches allow for avoidance of tracheostomy in many patients. Developments in dynamic procedures with the aim of restoring laryngeal function allow for adequate airway management while maintaining voice quality and limiting aspiration risk.

Etiological profile of upper airway obstruction in infants

Background

Respiratory distress is recognized as any sign of breathing difficulty in infants. Some congenital anomalies present immediately with airway distress, while others are asymptomatic or discovered later in infancy or childhood. Our objectives are to detect different laryngeal causes of respiratory distress in infants and to measure the relative risk of some variables like age, sex, family history, and other congenital anomalies for developing laryngeal causes of respiratory distress. This observational cross-sectional study was carried out during the period from June 2017 to December 2018 at Children’s University Hospital. The study included 80 infants who presented with respiratory distress and admitted to the hospital. All patients subjected to a detailed history from their parents and full general and ENT examinations. X-ray, MSCT neck or direct laryngoscope were carried out in selected cases.

Results

As regard age, 58% of cases were between 1–6 months, 28% of cases between 6 months and 1 year, and 14% between 1–2 years. Laryngeal causes of respiratory distress among infants were distributed as follow: 70% laryngomalacia, 18% subglottic stenosis, 8% laryngeal web, and 4% of cases were caused by vocal fold paralysis (VFP). The laryngeal causes of respiratory distress did not reveal any statistically significant difference among different age groups or between both genders (P = 0.257, 0.286; respectively). Also, there was no statistically significant difference between infants with positive family history and those without as regard the laryngeal causes of respiratory distress (P = .378).

Conclusion

The majority of respiratory distress cases (58%) were between 1–6 months. Bivariant analysis of variables age, sex, family history, and other congenital anomalies showed that they were not potent risk factors for developing laryngomalacia, subglottic stenosis, laryngeal web, and vocal fold paralysis. Laryngomalacia represented the commonest cause of respiratory distress (70%) followed by subglottic stenosis (18%), then laryngeal web (8%), and finally the vocal fold paralysis represented the least percentage (4%). Apart from laryngomalacia, the percentages of other causes seem to vary according to sample size and geographic area of study. So, being familiar with the common causes of respiratory distress in a given region is very essential in order not to miss a potentially life-threatening diagnosis.

Endoscopic anterior-posterior cricoid split to avoid tracheostomy in infants with bilateral vocal fold paralysis

INTRODUCTION

Infants with bilateral vocal fold paralysis (BVFP) can present with stridor and respiratory distress necessitating tracheostomy. The endoscopic anterior-posterior cricoid split (APCS) with balloon dilation procedure has been described as an alternative to tracheostomy in these patients. Here, we report our institution's preliminary experience with APCS and evaluate patient factors that may predispose to the success or failure of this procedure in infants with BVFP.

METHODS

Electronic charts of patients who underwent APCS with balloon dilation at a single institution were reviewed for the following variables: patient demographics, comorbidities, etiology of vocal fold paralysis, symptoms at presentation, need for respiratory support, intra-operative findings, duration of intubation, perioperative medical treatments, subsequent airway management, and findings of follow-up evaluations. APCS was considered successful if the patient did not undergo tracheostomy.

RESULTS

Six patients underwent APCS with balloon dilation between August 2014 and October 2019. Four patients (66.7%) were male, and 5 of 6 (83.3%) were born full term. The etiology of vocal fold paralysis was idiopathic in four patients (66.7%) and associated with a neuromuscular disorder and hydrocephalus in the remaining two patients. Mean age at the time of the procedure was 10.3 weeks. Three infants (50%) avoided tracheostomy and had marked alleviation of airway symptoms. Three patients who required tracheostomy had more severe respiratory symptoms pre-operatively, requiring either intubation or positive pressure support. Among all patients, there were no mortalities in our series.

CONCLUSION

APCS is safe and may be effective at the elimination of airway symptoms in select infants with BVFP, avoiding the need for tracheostomy, however more investigation is needed to establish its precise role in this patient population.

Utility of polysomnography and video swallow studies in the management of pediatric patients with congenital idiopathic bilateral vocal fold dysfunction

OBJECTIVES

Congenital idiopathic bilateral vocal fold dysfunction (BVFD) is an uncommon cause of neonatal stridor and respiratory distress postnatally. Approximately 50% of affected neonates or infants will historically require tracheostomy for this condition. Timing and candidacy for tracheostomy in BVFD patients is often subjective and poorly understood. Polysomnography (PSG) and video swallow studies (VSS) may be helpful in the management of patients with BVFD prior to tracheostomy by quantifying their degree of upper airway obstruction during sleep and feeding dysfunction while awake.

METHODS

We performed a single-institution retrospective case series of BVFD patients from 2000 to 2018 who had postnatal PSGs performed prior to tracheostomy. Demographics, gestational age, and VSS results prior to PSG were recorded for all patients. Findings from PSGs included non-REM AHI, REM AHI, oxygen nadir, % total sleep time (TST) O2<90%, peak end-tidal (ET) CO2, % TST ETCO2 >52 torr. Rates of post-PSG tracheostomy, gastrostomy tube (G-tube) placement, and home O2 supplementation were noted for all patients.

RESULTS

From 2000 to 2018, 12/46 (26%) BVFD patients had postnatal PSGs performed prior to tracheostomy. Median patient age at BVFD diagnosis, VSS, and PSG was 5.5 days, 12.5 days, and 17.5 days, respectively. Mild, moderate, and severe obstructive sleep apnea (OSA) was found in 7/12, 3/12, and 4/12 patients, respectively. Hypercapnia (ETCO2 >52 torr) was found in 5/12 patients on PSG while hypoxemia (SpO2 <90% for >4% TST) was not found in any patient. VSS results demonstrated normal swallowing, inconsistent laryngeal penetration, and silent aspiration in 7/12, 2/12, and 3/12 patients, respectively. Tracheostomy and G-tube placement was performed in 3/12 and 2/12 patients, respectively. There was no association between the severity of OSA or any PSG abnormality, VSS findings, and the performance of tracheostomy in any BVFD patient.

CONCLUSIONS

OSA was found in all BVFD patients undergoing postnatal PSG at our institution while feeding dysfunction was found in approximately 50% of patients. The presence of feeding dysfunction, severe OSA, or any PSG abnormality was not individually associated with the subsequent performance of a tracheostomy in our patients. PSG is likely useful in supporting but not supplanting one's clinical decision-making in the management of patients with congenital idiopathic BVFD.

Multi-institutional Evaluation of Radiologic Findings Associated With Pediatric Congenital Idiopathic Bilateral Vocal Fold Dysfunction

OBJECTIVE

To report brain magnetic resonance imaging (MRI) and ultrasonography findings in pediatric patients with congenital idiopathic bilateral vocal fold dysfunction and analyze factors associated with its etiology and resolution.

STUDY DESIGN

Case series with retrospective review.

SETTING

Tertiary care multi-institutional setting: Nationwide Children's Hospital, Indiana University, University of North Carolina, and Cleveland Clinic.

METHODS

Pediatric patients with congenital idiopathic bilateral vocal fold dysfunction were included in this review.

RESULTS

Congenital idiopathic bilateral vocal fold dysfunction was identified in 74 patients from 2000 to 2018. Brain MRI scans were performed in all patients and ultrasonography in 30 (40.5%). Normal imaging results were most commonly found in patients born full-term (P < .0001) or via vaginal delivery (P < .01). Abnormal brain MRI and ultrasound results were found in 38 of 74 (51.3%) and 16 of 30 (53.3%), respectively. Type I Chiari malformation was not identified in any patient. No specific brain MRI or ultrasound abnormality was associated with patients' bilateral vocal fold dysfunction. Complete/incomplete bilateral vocal fold resolution occurred in 45 of 74 (60.8%) patients over the study interval and was not associated with brain MRI or ultrasound findings or birth complications but was associated with vaginal delivery (P = .02). Resolution rates were highest for patients with bilateral vocal fold paramedian paralysis (P = .05).

CONCLUSIONS

In this multi-institutional study, no specific brain MRI or ultrasound abnormality was associated with patients' bilateral vocal fold dysfunction or subsequent resolution rates. While imaging is often performed to detect and treat any reversible causes of bilateral vocal fold dysfunction, in this series, imaging findings were heterogeneous and did not identify any treatable causes, such as type I Chiari malformation.

Surgical Management of Bilateral Vocal Fold Paralysis in Children: A Systematic Review and Meta-analysis

OBJECTIVES

To examine and compare the outcomes of various types of glottic widening surgery (GWS) for initial management of bilateral vocal fold paralysis (BVFP) in children, the outcomes of different GWS procedures in children who underwent initial tracheostomy, and the rate of decannulation in children who underwent tracheostomy alone versus tracheostomy followed by GWS.

DATA SOURCES

PubMed, Web of Science, Cochrane Library, and Embase were searched following the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-analyses) on September 9, 2019, with no date restriction.

REVIEW METHODS

Articles focusing on GWS or tracheostomy for initial management of BVFP were included. Articles describing patients who received no surgical intervention for BVFP were excluded.

RESULTS

A total of 5989 articles were reviewed: 67 articles met inclusion criteria, and 240 patients were incorporated into the analysis. Patients who underwent primary GWS had an eventual tracheostomy rate of 6.0% (5/83). There were no statistically significant differences in the rate of tracheostomy, reoperation, or mortality among cricoid split, suture lateralization, and cordectomy/cordotomy. Patients who underwent primary tracheostomy failed to achieve decannulation in 36.9% (58/157) of cases. Decannulation was more likely in tracheostomized children who received GWS than those who did not (odds ratio, 6.336; P < .0001).

CONCLUSIONS

Most children who undergo primary GWS for BVFP avoid tracheostomy or reoperation. These data demonstrated no differences in surgical outcomes among the most common types of GWS for BVFP. For children who receive a tracheostomy as their first intervention for BVFP, GWS is associated with a significantly improved rate of decannulation.

Neonatal Vocal Fold Paralysis

Vocal fold paralysis (VFP) is an important cause of respiratory and feeding compromise in infants. The causes of neonatal VFP are varied and include central nervous system disorders, birth-related trauma, mediastinal masses, iatrogenic injuries, and idiopathic cases. Bilateral VFP often presents with stridor or respiratory distress and can require rapid intervention to stabilize an adequate airway. Unilateral VFP presents more subtly with a weak cry, swallowing dysfunction, and less frequently respiratory distress. The etiology and type of VFP is important for management. Evaluation involves direct visualization of the vocal folds, with additional imaging and testing in select cases. Swallowing dysfunction, also known as dysphagia, is very common in infants with VFP. A clinical assessment of swallowing function is necessary in all cases of VFP, with some patients also requiring an instrumental swallow assessment. Modification of feeding techniques and enteral access for feedings may be necessary. Airway management can vary from close monitoring to noninvasive ventilation, tracheostomy, and laryngeal surgery. Long-term follow-up with otolaryngology and speech-language pathology service is necessary for all children with VFP to ensure adequate breathing, swallowing, and phonation. The short- and long-term health and quality-of-life consequences of VFP can be substantial, especially if not managed early.

Endoscopic arytenoid abduction lateropexy for the treatment of neonatal bilateral vocal cord paralysis - Long-term results

OBJECTIVES

Bilateral vocal cord paralysis often causes severe dyspnea requiring an early airway intervention in neonates. Endoscopic arytenoid abduction lateropexy (EAAL) with suture is a quick, reversible, minimally-invasive vocal cord lateralizing technique to enlarge the glottis. The arytenoid cartilage is directly lateralized to a normal abducted position. It can be performed even in early childhood with the recently-introduced pediatric endoscopic thread guide instrument. The long-term results and the stability of the lateralization were evaluated.

METHODS

Three newborns had inspiratory stridor immediately after birth. Laryngo-tracheoscopy revealed bilateral vocal cord paralysis. Unilateral, left-sided endoscopic arytenoid abduction lateropexy was performed with supraglottic jet ventilation. The follow-up period was >3 years.

RESULTS

After extubation on the 4-7th postoperative day no dyspnea or swallowing disorder occurred. Laryngo-tracheoscopy, clinical growth charts and voice analysis showed satisfactory functional results.

CONCLUSIONS

The endoscopic arytenoid abduction lateropexy might be a favorable solution for neonatal bilateral vocal cord paralysis. In one step, airway patency can be achieved without irreversible damage to the glottic structures. Normal swallowing function was preserved. The results are durable, and neither medialization nor dyspnea re-appeared during observation.

Management and outcomes of pediatric vocal cord paresis in Chiari malformation

INTRODUCTION

Pediatric vocal cord paresis (VCP) has a variety of etiologies, including congenital neurologic disease. Arnold-Chiari Malformation (ACM) is one such disease with known VCP association. However, the natural history, need for tracheostomy, and rate of decannulation in this patient population is not well characterized.

OBJECTIVE

To provide prognostic information on infants with ACM and VCP.

METHODS

A retrospective chart review was conducted of patients with both ACM and VCP at a single institution. Clinical outcomes and disease progression were determined using flexible laryngoscopy, serial clinical exams, and operative reports from otolaryngology and neurosurgery services.

RESULTS

Eighteen patients were included in this study, four with ACM Type I and 14 with ACM Type II. These groups were analyzed separately. For ACM I, the average age at diagnosis was 25 months and two (50%) required tracheostomy. Three subjects (75%) achieved VCP resolution, with two doing so after neurosurgical decompression. For ACM II, the average age at diagnosis was eight months and 12 patients (86%) underwent tracheostomy. Four subjects with tracheostomy (33%) achieved decannulation, with three of these demonstrating VCP resolution. In total, six ACM II patients had complete and one had partial VCP resolution, all of whom underwent decompression. Two patients initially had normal endoscopic exams despite stridor and VCP was only noted on serial exams.

DISCUSSION

This study represents the largest series of pediatric patients with VCP and ACM. The majority needed decompression (80%) and tracheotomy (78%). Tracheostomy decannulation typically occurred only after decompression and resolution of VCP. No children diagnosed at age <1 month were decannulated. Early decompression was associated with successful avoidance of tracheostomy in majority of Chiari I but not Chiari II patients. Serial endoscopies were required to confirm VCP in some patients. This information could potentially aid in management and counseling parents of children with VCP and CM.

Endoscopic percutaneous suture lateralization for neonatal bilateral vocal fold immobility

OBJECTIVE

Bilateral vocal-fold immobility (BFVI) is a rare but significant cause of severe respiratory distress in neonates. The primary aim of treatment is to provide an adequate airway while minimizing adverse effects such as aspiration and dysphonia. Our objective here is to describe the outcomes of a series of neonates undergoing percutaneous endoscopic suture lateralization for BVFI using a novel technique.

METHODS

In this retrospective case series, we present 6 neonates (mean age: 18 days) with BVFI from three tertiary academic medical centers. The etiologies included 4 idiopathic, 1 unspecified neurodegenerative disorder, and 1 acquired from cardiac surgery. All had stridor and respiratory distress with hypoxemia requiring respiratory support at diagnosis. Endoscopic vocal-fold lateralization was performed under spontaneous-breathing suspension laryngoscopy using a novel technique of percutaneous needle-directed placement of 4-0 prolene suture without use of specialized equipment.

RESULTS

All patients had clinical improvement in stridor and respiratory support requirements and avoided tracheostomy. One patient had persistent aspiration after lateralization that resolved after suture removal. One patient required bilateral lateralization procedures. One patient expired of epilepsy due to neurodegenerative disease unrelated to airway pathology. At last follow-up (mean 12.6 months), 5/5 remaining patients were on room air without tracheostomy and feeding orally without aspiration; 4/5 had partial or complete return of vocal-fold function.

CONCLUSION

Endoscopic percutaneous suture lateralization may be a safe and effective non-destructive primary treatment modality for neonatal BVFI. All neonates undergoing this procedure avoided tracheotomy.

Vocal Fold Immobility due to Birth Trauma: A Systematic Review and Pooled Analysis

Objectives

To describe the present understanding of birth trauma–related vocal fold immobility and quantitatively compare it with idiopathic congenital vocal fold immobility to explore whether it is a discrete entity.

Data Sources

PubMed, Ovid, and Cochrane databases.

Review Methods

English-language, observational, or experimental studies involving infants with idiopathic congenital or birth trauma–related vocal fold immobility were included. Data from these studies were pooled with our institution’s vocal fold immobility database, with the resultant idiopathic congenital and birth trauma cohorts compared regarding patterns and outcomes of immobility.

Results

The search returned 288 articles, with 24 meeting inclusion criteria. Of studies reviewing all-cause immobility, 8 of 9 (88.9%) identified birth trauma as an etiology, although birth trauma definitions and proposed mechanisms of immobility varied. The study subjects, combined with our institution’s database, yielded 188 idiopathic congenital and 113 birth trauma cases. Compared with idiopathic congenital cases, birth trauma cases had a higher proportion of unilateral immobility (72 of 113 [63.7%] vs 52 of 188 [27.7%], P < .001) and rate of resolution (41 of 51 [80.4%] vs 91 of 159 [57.2%], P = .003). Resolution occurred in 24 of 26 (91.3%) unilateral and 17 of 25 (68.0%) bilateral birth trauma cases and in 30 of 40 (75.0%) unilateral and 59 of 109 (54.1%) bilateral idiopathic congenital cases ( P = .11 and .20, respectively).

Conclusion

While the definition and mechanism of birth trauma–related vocal fold immobility warrant further investigation, these findings suggest that it is distinct from idiopathic congenital vocal fold immobility, with a unique presentation and potentially more favorable outcomes. This can inform counseling and management for infants with otherwise unexplained immobility but known birth trauma.

Endoscopic management of bilateral vocal fold paralysis in newborns and infants

INTRODUCTION

Bilateral vocal cord paralysis in adducted position (BVCPAd) is a severe cause of airway obstruction and usually debuts with stridor and airway distress necessitating immediate intervention. Tracheostomy has long been the gold standard for treating this condition, but has significant associated morbidity and mortality in pediatric patients. New conservative procedures have emerged to treat this condition thus avoiding tracheostomy, like endoscopic anterior and posterior cricoid split (EAPCS). The objective of this paper was to review our experience with EAPCS in newborns and infants.

METHODS

Prospective study involving patients undergoing endoscopic EAPCS for symptomatic BVCPAd. The primary outcomes were tracheostomy avoidance and resolution of airway symptoms.

RESULTS

Three patients underwent EAPCS between January 2016 and December 2016. All patients stayed at least 7 days in the Intensive Care Unit (ICU) intubated. All patients presented complete resolution of their symptoms due to airway obstruction, without the need for tracheostomy.

CONCLUSION

EAPCS is a novel and effective alternative to treat BVCPAd in patients under 1 year old. Our study is an initial experience; more cases are required to identify the real impact and benefits of this technique and to determine the proper selection of patients.

Bilateral Congenital Vocal Cord Paralysis: A 16-Year Institutional Review

Objective:

To review the management and outcome of bilateral congenital true vocal cord paralysis in 22 patients treated over a 16-year period and to review the role of tracheostomy in these patients.

Design:

Retrospective chart review.

Setting:

Pediatric tertiary hospital.

Patients:

Twenty-two pediatric patients diagnosed with bilateral congenital true vocal cord paralysis.

Interventions:

Flexible or rigid diagnostic evaluation, tracheostomy, and vocal cord lateralization procedures.

Main Outcomes Measures:

Vocal cord recovery and decannulation.

Results:

With a mean follow up of 50 months, 15 of 22 patients (68%) with bilateral vocal cord paralysis required tracheostomy for airway securement. Of the 15 tracheotomized patients, 10 were successfully decannulated (8 had spontaneous recovery, whereas 2 required lateralization procedures). Eleven of these patients with tracheostomy had comorbid factors, including neurologic abnormalities (midbrain/brainstem dysgenesis, Arnold-Chiari malformation, global hypotonia, and developmental delay). Of the 7 patients not requiring tracheostomy, 6 recovered vocal cord function (86%).

Conclusion:

In our series of 22 patients with bilateral vocal cord paralysis, 14 had spontaneous recovery of function. Patients managed with tracheostomy were noted to have a high incidence of comorbid factors. In this series, recovery rates were found to be higher in nontracheostomized patients than in tracheostomized patients. Patients can be carefully selected for observation versus tracheostomy at the time of diagnosis based on underlying medical conditions.

Pediatric vocal fold paralysis after cardiac surgery: Rate of recovery and sequelae

Objective

To determine the rate of recovery of pediatric vocal fold paralysis (VFP) after cardiac surgery.

Study Design and Setting

Retrospective case series from January 2000 to 2005 at 4 tertiary care pediatric hospitals.

Results

A total of 109 children with VFP were identified. Of 80 patients with follow-up >3 months, 28 (35%) recovered vocal fold function with a median time to diagnosis of recovery of 6.6 months. Fifty-two (65%) patients had persistent vocal fold paralysis with a median follow-up time of 16.4 months. Twenty-five (45%) of 55 patients demonstrated aspiration or laryngeal penetration with modified barium swallow. Twenty-nine (27%) of the 109 patients underwent surgical intervention for their airway, feeding, or voice.

Conclusions

Pediatric VFP is not an uncommon complication after cardiac surgery and can result in serious sequelae. This study demonstrates a 35% rate of recovery, 45% rate of aspiration, and 27% rate of complications that require surgical intervention. © 2007 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.

Spontaneous recovery of bilateral congenital idiopathic laryngeal paralysis: systematic non-meta-analytical review

OBJECTIVES

To systematically review the frequency and time to spontaneous recovery in pediatric patients with bilateral congenital idiopathic laryngeal paralysis (BCILP).

METHODS

The databases of Medline, EMBASE, Scopus, CINAHL, Cochrane Library and Proquest Dissertations were searched for English language articles reporting on laryngeal paralysis in pediatric patients. A bibliography search of the selected studies was done to identify additional articles. We included prospective or retrospective case-series studies of children and neonates diagnosed with BCILP at age <60 days and confirmed by direct laryngoscopy, with sufficient follow up and objective assessment for recovery. Two authors independently extracted the data and assessed the quality of each study. Discrepancies were resolved by consensus and adjudication by a third author.

RESULTS

Of the 4229 articles identified by the search, only one study met our inclusion criteria. The study was a retrospective case series, and was of low quality. The mean age at diagnosis was fourteen days. Sixty-five percent of the patients recovered spontaneously, and the mean time to recovery was twenty-five months. Tracheostomy was performed in 71% of the patients.

CONCLUSIONS

The available literature is of low quality and provides weak evidence on the natural history of BCILP in pediatric population.

Clinically silent subdural hemorrhage causes bilateral vocal fold paralysis in newborn infant

Bilateral congenital vocal fold paralysis (BVFP) may result from multiple etiologies or remain idiopathic when no real cause can be identified. If obstructive dyspnea is significant and requires urgent stabilization of the airway, then intubation is performed first and an MRI of the brain is conducted to rule out an Arnold-Chiari malformation that can benefit from a shunt procedure and thus alleviate the need for a tracheostomy. Clinically silent subdural hemorrhage without any birth trauma represents another cause of neonatal BVFP that resolves spontaneously within a month. It is of clinical relevance to recognize this potential cause of BVFP as its short duration may alleviate the need for a tracheostomy. In this article, we present such a case and review the literature to draw the otolaryngologist's attention to this possible etiology.

Laser arytenoidectomy in the management of bilateral vocal cord paralysis in children

OBJECTIVE

To analyse the efficacy of CO(2) laser arytenoidectomy in the management of bilateral vocal cord paralysis in children.

METHODS

Retrospective series of 17 patients who underwent laser arytenoidectomy for bilateral vocal cord between 1995 and 2008 in a tertiary care institution. All patients had bilateral laryngeal paralysis, in isolation (n=5) or associated with concomitant airway conditions (n=12). All cases had anterior prolapse of the arytenoids with partial obstruction of the airway on inspiration. 12/17 patients (70.5%) were tracheotomy-dependant, 2/17 were in-extubatable, and 3/17 had severe airway limitation, effort dyspnea and poor sleep pattern. Main outcome measures were decannulation rate for patients with tracheotomy, occurrence of aspiration and quality of voice.

RESULTS

The mean age was 2.8 years old. 9/12 patients with tracheotomy (75%) were decannulated with a median delay of 2 months (2 days to 18 months). Both of the intubated patients were extubated with a median delay of 36h. One of the decannulated patients who re-presented with a residual dyspnea after the arytenoidectomy was improved by a further laser cordotomy. 2/17 patients (11.7%) had post-operative persistent aspirations (with pneumopathies in one case), 5/17 patients were dysphonic, 3 improved with speech therapy and 2 with intracordal lipoinjection.

CONCLUSIONS

Laser arytenoidectomy is effective for improving the breathing in children presenting with a bilateral vocal fold paralysis associated with obstructive arytenoid prolapse. Results are good as a first-line surgery or following laryngo-tracheal surgery. Voice outcomes are satisfactory. However, aspiration is a rare complication.

Congenital Bilateral Vocal Fold Paralysis and Charcot-Marie-Tooth Disease

We present the case of a patient with Charcot-Marie-Tooth disease (CMT) type 1 with congenital bilateral vocal fold paralysis in order to emphasize the treatment options and long-term outcome. The case is reviewed with regard to presentation, differential diagnosis, and treatment. We also reviewed the literature to determine the frequency of congenital and childhood presentations of bilateral vocal fold paralysis associated with CMT, most specifically CMT type 1. We found only 14 children reported to have bilateral vocal fold paralysis associated with CMT, and only 1 of these cases was associated with CMT type 1. None of these patients had congenital vocal fold paralysis. Because of the degenerative nature of the disease, our patient underwent endoscopic cordotomy to avoid tracheotomy. We conclude that CMT should be included in the differential diagnosis in evaluating neonates with bilateral vocal fold paralysis. If CMT is definitively diagnosed, it could alter the course of treatment.

Applications of flexible bronchoscopy in infants with congenital vocal cord paralysis: a 12-year experience

BACKGROUND

Congenital vocal cord paralysis (VCP) is a common cause of congenital stridor. Before the widespread application of flexible bronchoscopy (FB) by pediatricians, congenital stridor in infants was usually attributed to laryngomalacia. Prompt recognition and careful follow-up is crucial for the management of congenital VCP.

METHODS

We performed a retrospective chart review of newborn infants with congenital VCP diagnosed by FB over a 12-year period.

RESULTS

During the 12-year period, FB was performed on a total of 356 infants. Fifteen (4%) infants were diagnosed with congenital VCP. There were eight males and seven females and the mean age at diagnosis was 76.6 days. Stridor with respiratory distress was the most prominent presenting symptom. The majority (93%, 14/15) demonstrated bilateral VCP, while one patient (7%) had unilateral VCP. Seven of the 15 (46%) patients had idiopathic VCP, while eight (54%) had VCP associated with neuromuscular disorders. Tracheotomy was necessary in four patients (26%). None of them underwent further surgical interventions. Spontaneous recovery occurred in 10 patients (71%), and of these, 90% (9/10) were treated without tracheotomy.

CONCLUSION

In order to allow prompt diagnosis of congenital VCP, FB should be performed in every newborn infant with stridor. Patients with congenital VCP should undergo additional imaging studies to detect any associated neurological abnormalities and intrathoracic comorbidities. The majority of patients can be managed conservatively and monitored carefully using serial FB. Corrective surgery should be reserved for those with a lack of resolution at prolonged follow-up, and those with significant comorbidities.

Injection of Botulinum Toxin into External Laryngeal Muscles in Pediatric Laryngeal Paralysis

Objectives:

I undertook to demonstrate the effect of injecting botulinum toxin type A (BTA) into cricothyroid, sternothyroid, and sternohyoid muscles in cases of bilateral laryngeal paralysis (BLP). Tracheostomy remains the consistently reproducible and accepted method to salvage the airway obstruction in BLP. The bypass, however, acknowledges the current lack of knowledge and consensus on the pathogenesis.

Methods:

I performed a retrospective chart review of BLP cases treated with BTA in a tertiary care pediatric center. The injections were performed under direct vision through an open transcervical approach. The main outcome measures used were improvement of airway symptoms and endoscopic findings, tracheostomy requirement, and incidence of recovery of function.

Results:

In total, 24 patients with BLP were identified. Over a 2-year period, 7 patients were treated with BTA. Six patients had congenital idiopathic BLP. One of these had trisomy 7. One patient acquired the paralysis after cardiac surgery. No patients required a tracheostomy, except for the infant with trisomy 7. Six patients recovered function completely, and the seventh recovered it partially (range, 4 weeks to 12 months).

Conclusions:

Injection of BTA into external laryngeal muscles may be an alternative to tracheostomy in BLP. It is proposed that the toxin relaxes the glottic aperture by paralyzing the cricothyroid and strap muscles and that it may aid in appropriate reinnervation of the larynx via mechanisms beyond the neuromuscular junction.

Correlation of glottal closure using concurrent ultrasonography and nasolaryngoscopy in children: a novel approach to evaluate glottal status

OBJECTIVES

Endoscopic procedures to assess aerodigestive symptoms by evaluating glottal motion are not practical in neonates because of small nares, respiratory difficulties, or additional stress. Our objective was to determine the temporal correlation between concurrent nasolaryngoscopy (NLS) and ultrasonography (USG) evaluation of glottal motion.

METHODS

Simultaneous USG of the glottis was performed in 10 subjects (5 males, 5 females, age = 4.5 months to 7.1 years) that underwent diagnostic flexible outpatient NLS. The USG transducer was placed on the anterior neck at the level of the vocal cords. The video signals from NLS and USG were integrated and synchronized into real-time cine loops of 1-min duration.

RESULTS

Frame-by-frame evaluation of 10,800 frames identifying glottal opening and closure time was compared between the two modalities by three observers and the timing of glottal closure was marked. Two investigators, blinded to NLS images, identified ultrasonographically determined glottal closure with 99% and 100% accuracy, and the mean probability of missing a closure frame was 0.007 (95% CI = 0.0008-0.024).

CONCLUSIONS

Temporal characteristics of glottal motion can be quantified by USG with perfect reliability and safety. This method can be useful in measuring the presence and the duration of laryngeal adduction.

Intraoperative laryngeal electromyography in children with vocal fold immobility: a simplified technique

OBJECTIVES

The primary objective of this study was to determine whether a simplified technique for intraoperative laryngeal electromyography was feasible using standard nerve integrity monitoring electrodes and audiovisual digital recording equipment. Our secondary objective was to determine if laryngeal electromyography data provided any additional information that significantly influenced patient management.

METHODS

Between February 2006 and February 2007, 10 children referred to our institution with vocal fold immobility underwent intraoperative laryngeal electromyography of the thyroarytenoid muscles. A retrospective chart review of these 10 patients was performed after institutional review board approval.

RESULTS

Standard nerve integrity monitoring electrodes can be used to perform intraoperative laryngeal electromyography of the thyroarytenoid muscles in children. In 5 of 10 cases reviewed, data from laryngeal electromyography recordings meaningfully influenced the care of children with vocal fold immobility and affected clinical decision-making, sometimes altering management strategies. In the remaining 5 children, data supported clinical impressions but did not alter treatment plans. Two children with idiopathic bilateral vocal fold paralysis initially presented with a lack of electrical activity on one or both sides but went on to develop motor unit action potentials that preceded recovery of motion in both vocal folds.

CONCLUSIONS

Our findings suggest that standard nerve monitoring equipment can be used to perform intraoperative laryngeal electromyography and that electromyographic data can assist clinicians in the management of complex patients. Additionally, there may be a role for the use of serial intraoperative measurements in predicting recovery from vocal fold paralysis in the pediatric age group.

Management of vocal paralysis: a comparison of adult and pediatric practices

OBJECTIVE

To compare practices of the American Broncho-Esophagological Association (ABEA) membership regarding the evaluation and management of unilateral vocal fold motion impairment (UVFMI) in adult versus pediatric populations.

STUDY DESIGN AND SETTING

An 18-item adult survey and 16-item pediatric survey were administered to ABEA members.

RESULTS

Seventy-six adult (31%) and 35 pediatric surveys (43%) were completed. Key differences are highlighted. With respect to etiology, the most common reported childhood cause is idiopathic; adults more often suffer iatrogenic paralysis. Children more commonly experience reflux disease, feeding difficulties, and choking. Preferred testing involves flexible laryngoscopy and chest x-ray; however, laboratory tests are carried out less often in children (51% vs 71%) and medical intervention is advocated by fewer pediatric practitioners (39% vs 57%).

CONCLUSION

Significant disparities exist in the etiology, presenting symptoms, diagnostic testing, and medical treatment between children and adults with UVFMI.

SIGNIFICANCE

Clinicians' perceptions regarding UVFMI may reflect the differing impact of vocal paralysis in the pediatric versus adult populations.

[Vocal fold paralysis in children: diagnostic and management from a case report]

Vocal fold paralysis accounts for 10% of the larynx congenital abnormality, being the second most common cause of laryngeal stridor in childhood. As to unilateral vocal fold paralysis, the main cause is left-sided iatrogenic injury to the recurrent laryngeal nerve, secondary to surgery to correct the patent ductus arteriosus. In this study we reviewed the literature, reporting a case of a child who, after having undergone surgery to close the patent ductus arteriosus, evolved with breathing difficulty and dysphonia. We suggest that flexible fiberoptic laryngoscopy is carried out pre- and post surgery in children for whom heart surgery to correct congenital abnormalities is indicated, thus allowing for early diagnosis of vocal fold paralysis and the selection of the best management approach.

Bilateral vocal cord paralysis in newborns with neuraxial malformations--two case reports--

Two neonates presented with inspiratory stridor due to bilateral vocal cord paralysis associated with occipital encephalocele, Chiari malformation, and hydrocephalus in one patient, and cervical meningomyelocele and Chiari malformation in the other patient. The clinical symptoms dramatically regressed after repair of the encephalocele or meningomyelocele with no requirement for craniovertebral decompressive procedures or shunts in the acute phase. Careful evaluation of neonatal stridor and recognition of vocal cord paralysis are important, as treatment of associated congenital central nervous system anomalies is likely to achieve satisfactory surgical results.

Pediatric unilateral vocal fold immobility

Unilateral VFI is a rare entity in the pediatric age group. Initial evaluation should include a thorough history and physical examination, particularly assessing for associated CNS and cardiovascular anomalies. Modalities of investigation include fiberoptic examination, EMG in the older child,diagnostic imaging, and rigid endoscopy. Controversy exists about the relevance of "growth centers" in the developing larynx, although recent studies dispute their existence. Recovery in idiopathic or congenital cases can occur up to 11 years later, which supports some observation between onset of paralysis and surgical intervention. In cases where the etiology is clear and recovery is not anticipated, a few reported series have demonstrated success with endoscopic injection and thyroplasty techniques. Unlike the case in adults, careful identification of the vocal fold level should be performed in children before implant placement. Further research is necessary to prove prospectively that surgical intervention in the pediatric larynx will not affect subsequent growth. Until this occurs, the otolaryngologist will continue to be challenged with decisions regarding the timing and choice of technique for correction of unilateral VFI in neonates and children.

The use of injectable collagen in the management of pediatric vocal unilateral fold paralysis

Vocal fold paralysis (VFP) is the second most common congenital abnormality that affects the larynx. Unilateral cases may be asymptomatic or feature symptoms related to laryngeal incompetence, such as aspiration and dysphonia. Management has traditionally been conservative as a high percentage of these paralyses recover spontaneously. The literature is scant on the acute or chronic management of unilateral vocal fold paralysis related symptoms in children. We present a series of four children (age 21 days, 5 years, 5 years, and 18 years) with unilateral VFP paralysis treated with collagen (Cymmtera) augmentation for control of symptoms related to laryngeal incompetence. Two children (age 21 days and 5 years) were managed in the acute setting. Follow-up has ranged from 4 to 12 months, and all have maintained excellent outcomes. Vocal fold augmentation with collagen is an effective therapeutic option in the management of symptoms related to unilateral VFP and laryngeal incompetence. It decreases the risk of aspiration and improves vocal quality. Collagen augmentation can be used in the acute setting to decrease aspiration, possibly avoiding a tracheotomy or gastrostomy tube placement, or to augment patients with a tracheotomy who are still severely aspirating.

Surgery for pediatric vocal cord paralysis: a retrospective review

To determine the outcome of surgical procedures for bilateral vocal cord paralysis in children, we performed a retrospective review of children under 18 years of age with bilateral vocal cord paralysis and a previous tracheotomy who underwent a primary procedure at a single tertiary care institution with an aim of decannulation. The primary outcome measure was the operation-specific decannulation rate (OSDR). The overall decannulation rates, as well as morbidity rates, were also recorded. Fifty-two children met the inclusion criteria (mean age at time of primary surgery, 6.2 years; SD, 5 years). Vocal cord lateralization procedures combined with a partial arytenoidectomy achieved the highest OSDR (17/24 or 71%). This OSDR was statistically higher than the OSDRs for CO2 laser cordotomy or arytenoidectomy procedures (OSDR, 5/17 or 29%, p = .008), for isolated arytenoidopexy procedures (OSDR, 1/4 or 25%, p = .000004), or for posterior costal cartilage graft procedures (OSDR, 3/5 or 60%, p = .0004). Neither of the 2 children who underwent isolated arytenoidectomy achieved primary decannulation. The incidence of aspiration following posterior cartilage graft procedures was 15% (2/15). Subanalysis by age failed to reveal differences in OSDR. We conclude that vocal cord lateralization procedures with partial arytenoidectomy afford the highest OSDR among primary procedures for pediatric vocal cord paralysis. The CO2 laser procedures, while having limited success as a primary procedure, are effective for revision.

Chiari I malformation in the very young child: the spectrum of presentations and experience in 31 children under age 6 years

INTRODUCTION

The entity of hindbrain herniation without myelodysplasia in the very young child has been poorly described. A retrospective analysis of children diagnosed with Chiari I malformation (CM I) before their sixth birthday is presented.

METHODS

Since 1985, 31 children with CM I (0.3-5.8) years of age have been diagnosed at University of Iowa Hospitals and Clinics. Their records were reviewed for presenting symptoms, signs, radiographic findings, treatment, complications, and outcome.

RESULTS

The average age at diagnosis was 3.3 years. Sixteen patients were under age 3. Chief presenting complaints included impaired oropharyngeal function (35%), scoliosis (23%), headache or neck pain (23%), sensory disturbance (6%), weakness (3%), and other (10%). Sixty-nine percent of children under age 3 had abnormal oropharyngeal function. Three patients under age 3 (19%) had undergone fundoplication and/or gastrostomy before diagnosis of CM I. Common physical findings included abnormal tendon reflexes (68%), scoliosis (26%), abnormal gag reflex (13%), and normal examination (13%). Vocal cord dysfunction (26%, all under age 3) and syringohydromyelia (52%) were also seen. Twenty-five patients were treated surgically at our institution with posterior fossa decompression, duraplasty, and cerebellar tonsillar shrinkage. Three patients were lost to follow-up. Ninety-one percent of patients reported improved symptomatology at last follow-up (mean: 3.9 years). Three patients required reoperation for recurrence of symptoms. Syringomyelia improved in all patients. Scoliosis resolved in 2 of 8 patients, improved in 5, and stabilized in 1. There was no permanent morbidity from surgery.

DISCUSSION

We show that children with Chiari I abnormality are very likely to present with oropharyngeal dysfunction if under age 3, and either scoliosis or headache or neck pain worsened by valsalva if age 3 to 5. These symptoms are very likely to improve after Chiari decompression, which can be done with low morbidity.

CONCLUSIONS

Very young children presenting with oropharyngeal dysfunction, pain worsened by valsalva, or scoliosis should prompt the clinician to consider CM I as a possible cause.

Surgery for pediatric vocal cord paralysis: a meta-analysis

OBJECTIVE

The study goal was to determine the impact of various surgical procedures for bilateral vocal cord paralysis in children by using established principles of meta-analysis.

STUDY DESIGN AND SETTING

We conducted a retrospective review of the literature in which a predetermined protocol was used to identify articles for meta-analysis. Six articles met inclusion criteria, and pertinent data were extracted.

RESULTS

Pooled data analysis demonstrated primary procedure-specific decannulation rates for external arytenoidopexy for 19 of 24 (79%), external arytenoidectomy for 14 of 19 (74%), CO2 laser arytenoidectomy for 4 of 10 (40%), and costal cartilage graft procedures for 2 of 2 (100%). External arytenoid procedures are more efficacious than CO2 laser procedures in terms of primary decannulation (P = 0.02).

CONCLUSION

Meta-analysis of the existing literature reveals that external arytenoidopexy and external arytenoidectomy are equivalently effective procedures and that the two combined are significantly more effective than CO2 ablative procedures.

SIGNIFICANCE

External procedures appear to be more effective as a first-line treatment in pediatric vocal cord paralysis, with arytenoidopexy with or without partial arytenoidectomy offering an attractive first-line surgical option.

The role of fibreoptic laryngoscopy in infants with stridor

Stridor in infants may be potentially serious and would require further investigations in all cases. Laryngomalacia is the most common cause of congenital stridor. This is a self-limiting condition with a good prognosis but other causes of stridor should be excluded to enable the surgeon to plan further intervention if needed. Traditionally microlaryngoscopy and bronchoscopy under a general anaesthetic is performed to evaluate the airway. We have investigated the use of the flexible fibreoptic laryngoscope under local anaesthetics in infants with inspiratory stridor. The procedure was performed in the day surgery unit on a non-fasting, non-sedated child. A retrospective analysis of procedures performed between January 1998 and August 1999 was carried out. Of the 43 patients studied, laryngomalacia was diagnosed in 35, vocal cord palsies in six and two infants had a normal larynx. There were no complications during the procedure and only one child required further intervention. The results showed that the combination of fibreoptic laryngoscopy under local anaesthetic with follow-up is a safe, effective and cost effective method of assessing stridor in this group of patients.

Congenital anomalies of the larynx and trachea

A variety of congenital anomalies arise within the laryngeal or tracheal airway. Symptoms primarily include airway obstruction, hoarseness, and difficulty feeding. The diagnosis is typically made by a combination of clinical presentation, physical examination, and endoscopic evaluation. Definitive intervention may be necessary requiring endoscopic or open laryngeal surgery. Some of the more common congenital laryngeal and tracheal anomalies are discussed with respect to their diagnostic evaluation, clinical presentation, and management.

Vocal cord paralysis in infants and children

Vocal cord paralysis is the second most common cause of neonatal stridor. Recognition of laryngeal paralysis warrants further evaluation for an underlying etiology as it is frequently a manifestation of a multisystem anomaly. Initial intervention must concentrate on airway stabilization and treatment of any underlying conditions. Management strategies should be individualized and focus on maintenance of a safe and stable airway, acquisition of intelligible speech, and deglutition without aspiration.

Management of congenital laryngeal malformations

Congenital malformations of the larynx are relatively rare but may be life-threatening. The most common causes include laryngomalacia, vocal cord paralysis, and subglottic stenosis. The last 20 years has seen major advances in the field of surgical correction of such anomalies also serving to reduce the number of tracheotomies in children and the inherent dangers they pose. Success rates for the most popular surgical procedures have been favorable. These include supraglottoplasty for cases of severe laryngomalacia, in which relief of respiratory symptoms has been shown to occur in excess of 80% of cases. Complication rate is low, although postoperative death has been reported. Failure usually occurs in patients with concomitant airway abnormalities including pharyngomalacia. Vocal cord lateralization for vocal cord paralysis with airway compromise is achieved by means of arytenoidopexy or arytenoidectomy, using the lateral approach. Arytenoidectomy also can be performed using laryngofissure or endoscopic laser excision. Subglottic stenosis is the 3rd most common congenital anomaly. Anterior or multiple cricoid splitting with cartilage graft interpositioning is usually performed. The success rates for these procedures has been shown to be approximately 90%.

Neuralgic amyotrophy presenting with bilateral vocal cord paralysis in a child: a case report

Acute stridor and bilateral vocal cord paralysis is not uncommon in the neonate but is unusual in the older child. We report the first case of bilateral vocal cord paralysis secondary to neuralgic amyotrophy, a peripheral polyneuropathy, in a 5-year-old child. An extensive workup revealed a paralyzed right hemidiaphragm, arm weakness and an EMG pattern consistent with neuralgic amyotrophy. Neuralgic amyotrophy is an uncommon disorder in pediatric patients which may involve cranial and peripheral nerves including the phrenic nerves and rarely the recurrent laryngeal nerves. We propose that the diagnosis be considered in children who present with bilateral vocal cord paralysis and other associated neurologic findings.

Vocal cord paralysis and hypoventilation in a patient with suspected Leigh disease

The authors report the case of a 16-month-old male with suspected Leigh disease, which was diagnosed on the basis of the clinical manifestations, abnormal lactate stimulation test, proton magnetic resonance spectroscopy, and neuroradiologic findings. Progressive stridor resulting from bilateral vocal cord paralysis and hypoventilation was evident. The authors suggest that for infants or children who exhibit vocal cord paralysis, mitochondrial disorders, such as Leigh disease, should be considered.

Laryngologic management of infants with the Chiari II syndrome

As a part of a prospective multi-disciplinary study, all children born with a Chiari II malformation within the Uppsala region during a 3-year period were evaluated for any difficulties in breathing or swallowing. The evaluation was repeated at regular intervals during their first 18 months. Direct laryngoscopies were performed using flexible fiberscopes. Four out of 22 children were found to have disturbed breathing. Among those, two suffered from central apnoeic spells as well as bilateral vocal fold motion impairment, one from apnoeic spells only and one from bilateral vocal fold motion impairment only. All four also had dysphagia with aspiration. Three of the children developed respiratory symptoms within the first 3 months and the symptoms of the fourth begun within the first 6 months. One infant with severe symptoms expired at the age of 3 months. The vocal fold paralysis, apnoeic spells and swallowing difficulties of another infant resolved following active neurosurgical management. The conclusion that laryngologic issues are prominent in the severe Chiari II syndrome was further supported by a review of four more cases managed in recent years. Laryngologic assessment in the neonatal period can help to raise the issue of early neurosurgical intervention as well as identify some of the infants who will need extensive habilitation. Screening of laryngeal function by means of flexible fiberoptic laryngoscopy is recommended.