Vocal fold medialization in children: injection laryngoplasty, thyroplasty, or nerve reinnervation?
ABSTRACT To review surgical interventions for pediatric unilateral vocal fold immobility (UVFI).
Retrospective medical chart review.
Two tertiary academic centers.
All children who underwent vocal fold medialization for dysphonia, with or without aspiration, from January 2004 to September 2006.
Injection laryngoplasty, ansa cervicalis-recurrent laryngeal nerve anastomosis, or thyroplasty.
Age, sex, intervention, etiology, time from onset of UVFI to surgery, subjective success in improving voice, subjective duration of improvement, and complications.
Twenty-seven procedures were performed in 15 patients (mean age, 10.6 years). Nineteen injection laryngoplasties, 3 thyroplasties (1 bilateral), 2 ansa cervicalis-recurrent laryngeal nerve reinnervation procedures, 1 adduction arytenoidopexy, and 1 cricothyroid joint subluxation were performed. Causes of UVFI included thoracic surgery in 6 cases (40%), prolonged intubation in 4 (26%), central nervous system neoplasm in 3 (20%), unknown etiology in 1 (7%), and anoxic brain injury in 1 (7%). The mean duration from onset of symptoms to treatment was 47 months. There was 1 surgical complication (postoperative aspiration pneumonia following thyroplasty while the patient was under local anesthesia). Parents reported a satisfactory outcome in all cases.
Injection laryngoplasty, thyroplasty, and nerve reinnervation can be performed in pediatric patients with good outcomes and an acceptable safety profile. This article describes the experiences of 2 institutions with phonosurgery for UVFI in children and provides insight into the advantages and disadvantages of each procedure. Prospective studies, with validated quality-of-life measurements, are needed to greater clarify the role of different types of phonosurgery in children with UVFI.
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ABSTRACT: Persistent vocal fold motion impairment after recurrent laryngeal nerve (RLN) injury is not characteristically due to absent reinnervation, but often results from spontaneous aberrant reinnervation (synkinesis). We administered local neurotoxins to selected laryngeal muscles after RLN injury to determine whether aberrant reinnervation could be selectively inhibited. Unilateral RLN transection was performed in 24 male rats. Three weeks later, the denervated laryngeal adductor complex was injected with phenol, high- or low-dose vincristine sulfate (VNC), or saline solution. One month later, rat larynges were evaluated via videolaryngoscopy and laryngeal electromyography (LEMG). Larynges from euthanized animals were analyzed via immunofluorescent staining for the presence of reinnervation. One animal that received phenol and 3 animals that received high-dose VNC died of toxicity-related complications. In the surviving neurotoxin-treated animals, videolaryngoscopy showed increased lateralization of the immobile vocal fold. Only 1 phenol-injected rat had adductor complex motor recruitment (score of 3+) with LEMG. The other neurotoxin-treated animals demonstrated an absence of adductor complex reinnervation, with only insertional activity and fibrillations (no motor units/recruitment). Spontaneous ipsilateral abductor reinnervation was not affected by the adductor injections. Low-dose VNC injections appear to be relatively safe and effective in selectively inhibiting spontaneous aberrant reinnervation after RLN injury in an animal model.The Annals of otology, rhinology, and laryngology 12/2009; 118(12):887-93. DOI:10.1177/000348940911801210 · 1.05 Impact Factor
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ABSTRACT: The larynx is situated between the pharynx and the trachea as part of the upper airway. It contributes to phonation, respiration, and protection of the tracheobronchial tree from aspirations. Laryngeal anatomy and physiology is complex, hence pathologies in structure and function can lead to a broad spectrum of symptoms. Although an otolaryngologist usually performs evaluations of the larynx, and the speech– language pathologist evaluates function in the context of voice and swallow, the pulmonary physician will also encounter patients with respiratory symptoms due to laryngeal diseases. For a bronchoscopist, therefore, detailed surveillance should include descriptions of functional and anatomical findings. Prior to an endoscopic examination, pertinent information, including clinical history, pulmonary function test, and computed tomography images should be reviewed, as laryngeal pathologies can cause non-specific signs and symptoms. A heightened clinical suspicion, therefore, can assist in identifying abnormal findings that can otherwise be missed on casual surveillance. This chapter will focus on laryngeal anatomy and function from the perspectives of the bronchoscopist. Computed tomography imaging of the larynx will also be discussed.Flexible Bronchoscopy, Third 01/2012: chapter Examination of the Larynx Through the Flexible Bronchoscope: pages 32 - 45; Blackwell Publishing Ltd..
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ABSTRACT: IMPORTANCE The clinical course and outcomes of pediatric vocal fold immobility (VFI) vary widely in the literature, and follow-up in these patients varies accordingly. A better understanding of the natural history of pediatric VFI is crucial to improved management. OBJECTIVE To characterize the natural history of pediatric VFI, including symptoms and rates of resolution and surgical intervention. DESIGN, SETTING, AND PARTICIPANTS Retrospective review at an academically affiliated private pediatric otolaryngology practice in a metropolitan area of all patients seen between July 15, 2001, and September 1, 2012, with a diagnosis of complete or partial VFI. After elimination of 92 incomplete or duplicate files, 404 patient records were reviewed for demographic characteristics, etiologies, symptoms, follow-up, resolution, and interventions. Follow-up records were available for 362 patients (89.6%). MAIN OUTCOMES AND MEASURES Resolution of VFI confirmed by repeated laryngoscopy, length of follow-up, and surgical intervention rates. RESULTS Among the 404 patients, left VFI was present in 66.8%, right VFI in 7.9%, and bilateral VFI in 25.3%. Median (range) age at presentation was 2.9 (0-528.1) months. Major etiological categories included cardiac surgery in 68.8%, idiopathic immobility in 21.0%, and neurologic disease in 7.4%. At presentation, 61.4% experienced dysphonia, 54.0% respiratory symptoms, and 49.5% dysphagia. Tracheotomy was performed in 25.7% and gastrostomy in 40.8%. Median (range) duration of follow-up among the 89.6% of patients with follow-up was 17.2 (0.2-173.5) months. Resolution evidenced by laryngoscopy was found in 28.0%, with a median (range) time to resolution of 4.3 (0.4-38.7) months. In patients without laryngoscopic resolution, median follow-up was 26.0 months, and 28.9% reported symptomatic resolution. CONCLUSIONS AND RELEVANCE The natural history of pediatric VFI involves substantial morbidity, with lasting symptoms and considerable rates of surgical intervention. In this large database, the majority of patients did not experience resolution. This suggests a need for more regimented follow-up in these patients, a recommendation for which is proposed here.03/2014; 140(5). DOI:10.1001/jamaoto.2014.81