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Katwala A, Anderson C, Thayer E, Hitzel D, Smith ME, Hoffman MR. Predominantly unilateral laryngomalacia in infants with unilateral vocal fold paralysis. Int J Pediatr Otorhinolaryngol 2024; 179:111922. [PMID: 38574651 DOI: 10.1016/j.ijporl.2024.111922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 03/05/2024] [Accepted: 03/20/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Neonatal unilateral vocal fold paralysis may arise iatrogenically, idiopathically, or in the context of an underlying neurologic disorder. Management is often supportive, focusing on diet modification to allow for safe oral feeding. We describe the clinical course of six infants with unilateral vocal fold paralysis who developed predominantly unilateral laryngomalacia ipsilateral to the affected vocal fold with associated severe respiratory symptoms and feeding difficulty. METHODS Retrospective review of six infants with unilateral vocal fold paralysis and predominantly unilateral laryngomalacia. Charts were reviewed for etiology of vocal fold paralysis, presenting symptoms, operative details, postoperative course, and outcomes for breathing and swallowing. RESULTS Etiology of vocal fold paralysis included cardiac surgery in four patients, intubation-related in one, and idiopathic in one. Presenting symptoms included increased work of breathing, stridor, feeding difficulty, respiratory failure requiring noninvasive respiratory support, and weak cry. All infants were on nasogastric tube feedings. Direct microlaryngoscopy with unilateral or predominantly unilateral (conservative contralateral aryepiglottic fold division) supraglottoplasty was performed. Stridor and work of breathing improved in all six patients within 1 week postoperatively. Oral feeding improved in three patients within 2 weeks. Three patients had persistent feeding impairment with improvement within one year. CONCLUSIONS Predominantly unilateral laryngomalacia may arise in the context of unilateral vocal fold paralysis. Addressing the ipsilateral cuneiform collapse can improve breathing and feeding. This may be an under-described phenomenon and represents an additional reason to include the otolaryngologist early in the care of infants with suspected possible new unilateral vocal fold paralysis. Breathing and swallow can improve post-operatively, but feeding may remain limited by the vocal fold paralysis and any medical comorbidities. Ongoing follow-up and collaboration with speech-language pathology to optimize feeding are important.
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Affiliation(s)
- Aditi Katwala
- University of Iowa, Department of Otolaryngology-Head and Neck Surgery, Iowa City, IA, 52242, USA
| | - Cody Anderson
- University of Utah, Department of Otolaryngology-Head and Neck Surgery, Salt Lake City, UT, 84113, USA
| | - Emma Thayer
- University of Iowa, Department of Otolaryngology-Head and Neck Surgery, Iowa City, IA, 52242, USA
| | - Danielle Hitzel
- University of Iowa, Department of Otolaryngology-Head and Neck Surgery, Iowa City, IA, 52242, USA
| | - Marshall E Smith
- University of Utah, Department of Otolaryngology-Head and Neck Surgery, Salt Lake City, UT, 84113, USA
| | - Matthew R Hoffman
- University of Iowa, Department of Otolaryngology-Head and Neck Surgery, Iowa City, IA, 52242, USA.
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Masaki N, Tatewaki H, Kumae M, Ochiai T, Koizumi T, Ono T, Sonota K, Kimura M, Ozawa A, Sai S. Clinical Prognosis of Vocal Cord Paralysis After Cardiothoracic Surgery in Infants. Pediatr Cardiol 2024; 45:40-47. [PMID: 38070026 DOI: 10.1007/s00246-023-03341-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 10/30/2023] [Indexed: 01/10/2024]
Abstract
We aimed to clarify the long-term outcomes and prognosis of vocal cord paralysis (VCP) after cardiothoracic surgery in infants as well as the usefulness of laryngeal ultrasound (LUS) as screening for VCP. Overall, 967 infants aged 1-year-old or younger who underwent cardiothoracic surgery between 2008 and 2022 were included in this study. We divided the patients into two groups based on the period on whether they underwent screening without or with LUS and compared the incidence of VCP between the groups. There were no differences in the patients' preoperative characteristics between the two periods, whereas the incidence of VCP was significantly higher in period 2 than in period 1 (11.0% vs. 3.2%, p < 0.0001). The incidence of VCP among the procedures, including aortic arch repair, was > 50% and significantly increased from period 1 to period 2. The sensitivity and specificity of LUS was 87% and 90%, respectively. Symptoms of VCP improved in 92% of patients. Repeated flexible laryngoscopy revealed that the residual rate of VCP was 68%, 52%, and 48% at 6, 12, and 24 months, respectively. In conclusion, symptoms of postoperative VCP improved in most cases; however, paralysis persisted in half of the patients. As a screening method, LUS is useful for evaluating postoperative VCP. A more accurate understanding of VCP is needed to improve postoperative outcomes.
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Affiliation(s)
- Naoki Masaki
- Department of Cardiovascular Surgery, Miyagi Children's Hospital, 4-3-17 Ochiai, Aoba-ku, Sendai, 989-3126, Japan
| | - Hideki Tatewaki
- Department of Cardiovascular Surgery, Miyagi Children's Hospital, 4-3-17 Ochiai, Aoba-ku, Sendai, 989-3126, Japan
| | - Masaru Kumae
- Department of Cardiovascular Surgery, Miyagi Children's Hospital, 4-3-17 Ochiai, Aoba-ku, Sendai, 989-3126, Japan
| | - Tomonori Ochiai
- Department of Cardiovascular Surgery, Miyagi Children's Hospital, 4-3-17 Ochiai, Aoba-ku, Sendai, 989-3126, Japan
| | - Taku Koizumi
- Department of Intensive Care Medicine, Miyagi Children's Hospital, Sendai, Japan
| | - Tanomo Ono
- Department of Intensive Care Medicine, Miyagi Children's Hospital, Sendai, Japan
| | - Kenji Sonota
- Department of Intensive Care Medicine, Miyagi Children's Hospital, Sendai, Japan
| | - Masato Kimura
- Department of Cardiology, Miyagi Children's Hospital, Sendai, Japan
| | - Akira Ozawa
- Department of Cardiology, Miyagi Children's Hospital, Sendai, Japan
| | - Sadahiro Sai
- Department of Cardiovascular Surgery, Miyagi Children's Hospital, 4-3-17 Ochiai, Aoba-ku, Sendai, 989-3126, Japan.
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Kerstein JS, Klepper CM, Finnan EG, Mills KI. Nutrition for critically ill children with congenital heart disease. Nutr Clin Pract 2023; 38 Suppl 2:S158-S173. [PMID: 37721463 DOI: 10.1002/ncp.11046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 06/28/2023] [Accepted: 07/04/2023] [Indexed: 09/19/2023] Open
Abstract
Children with congenital heart disease often require admission to the cardiac intensive care unit at some point in their lives, either after elective surgical or catheter-based procedures or during times of acute critical illness. Meeting both the macronutrient and micronutrient needs of children in the cardiac intensive care unit requires complex decision-making when considering gastrointestinal perfusion, vasoactive support, and fluid balance goals. Although nutrition guidelines exist for critically ill children, these cannot always be extrapolated to children with congenital heart disease. Children with congenital heart disease may also suffer unique circumstances, such as chylothoraces, heart failure, and the need for mechanical circulatory support, which greatly impact nutrition delivery. Guidelines for neonates and children with heart disease continue to be developed. We provide a synthesized narrative review of current literature and considerations for nutrition evaluation and management of critically ill children with congenital heart disease.
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Affiliation(s)
- Jason S Kerstein
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusettes, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusettes, USA
| | - Corie M Klepper
- Department of Pediatrics, Harvard Medical School, Boston, Massachusettes, USA
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusettes, USA
| | - Emily G Finnan
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusettes, USA
| | - Kimberly I Mills
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusettes, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusettes, USA
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Biot T, Fieux M, Henaine R, Truy E, Coudert A, Ayari-Khalfallah S. Long term outcome of laryngeal mobility disorder and quality of life after pediatric cardiac surgery. Int J Pediatr Otorhinolaryngol 2022; 158:111142. [PMID: 35580383 DOI: 10.1016/j.ijporl.2022.111142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 02/15/2022] [Accepted: 04/11/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Laryngeal mobility disorder after a pediatric heart surgery is common (between 5 and 10% of cases), and has important consequences on swallowing, breathing and speaking. After reviewing the literature, the recovery rate is variable and the postoperative follow-up is often done on a short time frame. The primary objective of the study is to describe the recovery from laryngeal mobility disorder with a follow-up time of at least 5 years. The secondary objective is to describe of the quality of life of the child in terms of phonation and swallowing, and to identify potential risk factors for a lasting laryngeal mobility disorder. METHODS We collected data (morphological characteristics and details of the procedures and medical care) on children who had undergone a heart surgery with risks of complications, between 2010 and 2015, and with a laryngeal mobility disorder detected after the surgery through nasal flexible laryngoscopy. During a follow-up consultation, carried at least 5 years after the surgery, we performed a nasal flexible laryngoscopy to assess whether or not the patient had recovered a full mobility of the larynx. Two questionnaires were also given to the patients, the pVHI and the PEDI EAT-10, to assess respectively the quality of their speech and of their swallowing function. RESULTS The recovery rate for a laryngeal mobility disorder more than 5 years after surgery was found to be 65% (9 children out of the 14 included in the study). We identified a risk factor for the persistence of a laryngeal mobility disorder after surgery: the presence of an associated genetic syndrome, p = 0.025. Children with persistent laryngeal mobility disorder have an impaired quality of life score, using the pVHI scale, which correlates well with the flexible laryngoscopy findings, p = 0.033. CONCLUSION Children with a lasting laryngeal mobility disorder have disabling respiratory and vocal symptoms in their daily lives. Nasal flexible laryngoscopy should therefore be systematically performed postoperatively after a surgery carrying risks. For improved patient management, early detection of these disorders by pharyngolaryngeal nasal flexible laryngoscopy in the aftermath of high-risk cardiac surgery is strongly advised, with prolonged follow-up.
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Affiliation(s)
- Thomas Biot
- Hospices Civils de Lyon, Hopital Edouard Herriot, Service d'ORL et de chirurgie cervico-faciale, Lyon cedex, F-69003, France
| | - Maxime Fieux
- Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Service d'ORL, d'otoneurochirurgie et de chirurgie cervico-faciale, Pierre Bénite cedex, F-69495, France; Université de Lyon, Université Lyon 1, F-69003, Lyon, France; Université Paris Est Creteil, INSERM, IMRB, F-94010, Créteil, France; CNRS ERL 7000, F-94010, Créteil, France.
| | - Roland Henaine
- Université de Lyon, Université Lyon 1, F-69003, Lyon, France; Department of Adult and Child Cardiovascular Surgery and Heart Transplantation, Louis Pradel Cardiologic Hospital, Bron, France
| | - Eric Truy
- Hospices Civils de Lyon, Hopital Edouard Herriot, Service d'ORL et de chirurgie cervico-faciale, Lyon cedex, F-69003, France; Université de Lyon, Université Lyon 1, F-69003, Lyon, France; Inserm U1028, Lyon Neuroscience Research Center, Equipe IMPACT, Lyon, France; Hospices Civils de Lyon, Service d'ORL Pédiatrique, Hôpital Femme Mère Enfants, Bron Cedex, F-69500, France
| | - Aurelie Coudert
- Hospices Civils de Lyon, Hopital Edouard Herriot, Service d'ORL et de chirurgie cervico-faciale, Lyon cedex, F-69003, France; Hospices Civils de Lyon, Service d'ORL Pédiatrique, Hôpital Femme Mère Enfants, Bron Cedex, F-69500, France
| | - Sonia Ayari-Khalfallah
- Hospices Civils de Lyon, Service d'ORL Pédiatrique, Hôpital Femme Mère Enfants, Bron Cedex, F-69500, France
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Srikanthan A, Scott S, Desai V, Reichert L. Neonatal Airway Abnormalities. CHILDREN 2022; 9:children9070944. [PMID: 35883928 PMCID: PMC9322467 DOI: 10.3390/children9070944] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 06/14/2022] [Accepted: 06/18/2022] [Indexed: 02/03/2023]
Abstract
Neonatal airway abnormalities are commonly encountered by the neonatologist, general pediatrician, maternal fetal medicine specialist, and otolaryngologist. This review article discusses common and rare anomalies that may be encountered, along with discussion of embryology, workup, and treatment. This article aims to provide a broad overview of neonatal airway anomalies to arm those caring for these children with a broad differential diagnosis and basic knowledge of how to manage basic and complex presentations.
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Affiliation(s)
| | - Samantha Scott
- Albany Medical College, Albany, NY 12208, USA; (A.S.); (S.S.); (V.D.)
| | - Vilok Desai
- Albany Medical College, Albany, NY 12208, USA; (A.S.); (S.S.); (V.D.)
- Department of Otolaryngology, Albany Medical Center, Albany, NY 12208, USA
| | - Lara Reichert
- Albany Medical College, Albany, NY 12208, USA; (A.S.); (S.S.); (V.D.)
- Department of Otolaryngology, Albany Medical Center, Albany, NY 12208, USA
- Correspondence:
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Incidence and risk factor of vocal cord paralysis following slide tracheoplasty for congenital tracheal stenosis: a retrospective observational study. Cardiol Young 2022; 32:579-583. [PMID: 34247683 DOI: 10.1017/s1047951121002663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Slide tracheoplasty for congenital tracheal stenosis (CTS) has been shown to improve post-operative outcomes, but the incidence and risk factors of vocal cord paralysis (VCP) following slide tracheoplasty remain unclear. This study aimed to review our experience of slide tracheoplasty for CTS with a focus on post-operative VCP. METHODS Twenty-eight patients, who underwent tracheal reconstruction with or without cardiovascular repair at Kobe Children's Hospital between June, 2016 and March, 2020 were enrolled in this retrospective observational study. They were divided into two groups based on the presence of a pulmonary artery sling (PA sling). Perioperative variables were compared between the two groups. RESULTS Twenty-one of the 28 patients underwent concomitant repair for associated cardiovascular anomalies, including 15 patients with PA sling. The overall incidence of VCP following slide tracheoplasty was 28.6%. The incidences of VCP were 46.7% in patients with CTS and PA sling, which were 14.3% in CTS patients without cardiovascular anomalies. The only risk factor associated with VCP following slide tracheoplasty was a concomitant repair for PA sling. Post-operatively, the duration of nasogastric tube feeding in patients with VCP was significantly longer than that in patients without VCP. CONCLUSIONS The incidence of VCP following slide tracheoplasty for CTS was high, especially in concomitant repair cases for PA sling. Routine screening and evaluation of VCP soon after post-operative extubation is required for its appropriate management.
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7
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Espinosa M, Ongkasuwan J. Pediatric Unilateral Vocal Fold Paralysis: Workup and Management. CURRENT OTORHINOLARYNGOLOGY REPORTS 2021. [DOI: 10.1007/s40136-021-00335-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Williamson CG, Verma A, Tran ZK, Federman MD, Benharash P. Clinical and Financial Outcomes Associated With Vocal Fold Paralysis in Congenital Cardiac Surgery. J Cardiothorac Vasc Anesth 2021; 36:208-214. [PMID: 33875352 DOI: 10.1053/j.jvca.2021.03.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/02/2021] [Accepted: 03/03/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Vocal fold paralysis (VFP) has proven to increase resource use in several surgical fields. However, its burden in congenital cardiac surgery, a specialty known to be associated with high resource use, has not yet been examined. The authors aimed to assess the impact of VFP on costs, lengths of stay, and readmissions following congenital cardiac surgery. DESIGN A retrospective analysis of administrative data. SETTING The 2010-2017 National Readmissions Database. PARTICIPANTS All pediatric patients undergoing congenital cardiac surgery. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Vocal fold paralysis was defined using International Classification of Diseases, Ninth and Tenth Revisions, diagnosis codes. The primary outcome of interest was 30-day nonelective readmissions and 90-day readmissions; costs, length of stay, and discharge status also were considered. Of an estimated 124,486 patients meeting study criteria, 2,868 (2.3%) were identified with VFP. Incidence of VFP increased during the study period (0.7% in 2010 to 3.2% in 2017, nptrend < 0.001). Rates of nonhome discharge (30.0% v 16.4%, p < 0.001), 30-day readmission (23.9% v 12.4%, p < 0.001), and 90-day readmission (8.3% v 4.4%, p = 0.03) were increased in the VFP cohort, as were lengths of stay (42.1 v 27.0 days, p < 0.001) and costs ($196,000 v $128,000, p < 0.001). After adjustment for patient and hospital factors, VFP was independently associated with greater odds of nonhome discharge (adjusted odds ratios [AOR], 1.66, 95% CI, 1.14-2.40), 30-day readmission (AOR, 1.58, 95% CI, 1.03-2.42), 90-day readmission (AOR, 2.07, 95% CI, 1.22-3.52), longer lengths of stay (+ 6.1 days, 95% CI, 1.3-10.8), and higher hospitalization costs (+$22,000, 95% CI, 3,000-39,000). CONCLUSIONS Readmission rates after congenital cardiac surgery are significantly greater among those with VFP, as are costs, lengths of stay, and nonhome discharges. Therefore, further efforts are necessary to increase awareness and reduce the incidence of VFP in this vulnerable population to minimize the financial burden of congenital cardiac surgery on the US medical system.
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Affiliation(s)
- Catherine G Williamson
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Zachary K Tran
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Myke D Federman
- Division of Pediatric Critical Care, UCLA Mattel Children's Hospital, University of California, Los Angeles, Los Angeles, CA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA.
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Chorney SR, Zur KB, Buzi A, McKenna Benoit MK, Chennupati SK, Kleinman S, DeMauro SB, Elden LM. Recorded Flexible Nasolaryngoscopy for Neonatal Vocal Cord Assessment in a Prospective Cohort. Ann Otol Rhinol Laryngol 2020; 130:292-297. [PMID: 32795099 DOI: 10.1177/0003489420950370] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Assessing vocal cord mobility by flexible nasolaryngoscopy (FNL) can be difficult in neonates. To date, prospective studies evaluating the incidence and diagnostic accuracy of vocal cord paralysis (VCP) after surgical patent ductus arteriosus (PDA) ligation are limited. It is unknown whether video FNL improves diagnosis in this population. This study compared video recordings with bedside evaluation for diagnosis of VCP and determined inter-rater reliability of the diagnosis of VCP in preterm infants after PDA ligation. METHODS Prospective cohort of preterm neonates undergoing bedside FNL within two weeks of extubation following PDA ligation. In a subset, FNL was recorded. Two pediatric otolaryngologists, blinded to the initial diagnosis, reviewed the FNL video recordings. RESULTS Eighty infants were enrolled and 37 with a recorded FNL were included in the cohort. Average gestational age at birth was 25.2 weeks (SD: 1.2) and postmenstrual age at FNL was 37.0 weeks (SD: 4.5), which was 9.5 days (SD: 14.7) after extubation following PDA repair. There were 6 diagnosed with left VCP (16.2%; 95% CI: 4.3-28.1%) at bedside, and 9 diagnosed by video review (24.3%; 95% CI: 10.5-38.1%) (P = .56). Videos confirmed all 6 VCP diagnosed initially, but also identified 3 additional cases. Though imperfect, reviewing FNL by video showed substantial reliability (kappa = .75), with 91.9% agreement. CONCLUSION Video recorded FNL most often confirms a bedside diagnosis of VCP, but may also identify discrepancies. Physicians should consider the limitations of diagnosis especially when infants persist with symptoms such as weak voice or signs of postoperative aspiration. LEVEL OF EVIDENCE 2b.
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Affiliation(s)
- Stephen R Chorney
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Otorhinolaryngology - Head and Neck Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Karen B Zur
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Otorhinolaryngology - Head and Neck Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Adva Buzi
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Otorhinolaryngology - Head and Neck Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Margo K McKenna Benoit
- Department of Otolaryngology, University of Rochester Medical Center, Rochester, NY, USA
| | - Sri K Chennupati
- Section of Otolaryngology, St. Christopher's Hospital for Children, Philadelphia, PA, USA
| | - Stacey Kleinman
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Sara B DeMauro
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Lisa M Elden
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Otorhinolaryngology - Head and Neck Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Abstract
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.
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Abstract
OBJECTIVES Surgery of the aortic arch poses risk of recurrent laryngeal nerve injury due to the anatomic proximity and can manifest as vocal cord dysfunction after surgery. We assessed risk factors for vocal cord dysfunction and calculated surgical procedure associated rates in young infants after congenital heart surgery. DESIGN Cross section analysis. SETTING Forty-four children's hospitals reporting administrative data to Pediatric Health Information System. PARTICIPANTS Cardiac surgical patients less than or equal to 90 days old and discharged between January 2004 and June 2014. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Overall, 2,319 of 46,567 subjects (5%) had vocal cord dysfunction, increasing from 4% to 7% over the study period. Of those with vocal cord dysfunction, 75% had unilateral partial paralysis. Vocal cord dysfunction was significantly more common in newborn infants (74%), those with aortic arch procedures (77%) and with greater surgical complexity. Rates of vocal cord dysfunction ranged from 0.7% to 22.4% across surgical procedure groups. Vocal cord dysfunction was significantly associated with greater use of: prolonged mechanical ventilation (53% vs 40%), diaphragmatic plication (3% vs 1%), feeding tube use (32% vs 8%), surgical airways (4% vs 2%), and prolonged length of stay (44 vs 21 d). Vocal cord dysfunction testing increased significantly over the study (6-14 %), and vocal cord dysfunction diagnosis increased almost two-fold (odds ratio, 1.9; 95% CI, 1.7-2.1) comparing the last to first study quarters with the increase in vocal cord dysfunction diagnosis occurring predominately in surgeries to the aortic arch supported by cardiopulmonary bypass. However, aortic procedures without cardiopulmonary bypass and nonaortic arch procedures were common surgeries accounting for 27% and 23% of vocal cord dysfunction cases despite low overall vocal cord dysfunction rates (3.7% and 2.6%). CONCLUSIONS Vocal cord dysfunction complicated all cardiac surgical procedures among infants including those without aortic arch involvement. Increased efforts to determine appropriate indications for prevention, screening and treatment of vocal cord dysfunction among young infants after congenital heart surgery are needed.
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García-Torres E, Antón-Pacheco JL, Luna-Paredes MC, Morante-Valverde R, Ezquerra-Pozo E, Ferrer-Martínez A, Villafruela MA, Jiménez-Huerta I, López-Díaz M, Carrillo-Arroyo I, Boni L. Vocal cord paralysis after cardiovascular surgery in children: incidence, risk factors and diagnostic options. Eur J Cardiothorac Surg 2019; 57:359-365. [DOI: 10.1093/ejcts/ezz190] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Revised: 05/12/2019] [Accepted: 05/30/2019] [Indexed: 11/12/2022] Open
Abstract
Abstract
OBJECTIVES
The aim of this study was to assess the incidence of vocal cord paralysis (VCP) in children after cardiovascular surgery. The secondary aims were to identify the factors potentially associated with VCP and to assess the diagnostic utility of laryngeal ultrasound (US).
METHODS
This study is a retrospective review of patients who underwent aortic repair, patent ductus arteriosus ligation and left pulmonary artery surgeries from 2007 to 2017. The following data were collected: patient demographics, gestational age, weight and age at surgery, comorbidities, cardiovascular anomaly and type of procedure, laryngoscopic and US evaluation results. Univariable and multivariable logistic regression models were used to identify the variables associated with VCP.
RESULTS
Two hundred and six patients were included in the study. Seventy-two patients (35%) were preterm and 32.5% showed comorbidities. At surgery, median age and weight were 0.6 months [interquartile range (IQR) 0.3–2.1] and 3.0 kg (IQR 1.3–4.0), respectively. Postoperatively, symptomatic patients underwent endoscopic evaluation and VCP was detected in 25 cases (12.1%). Laryngeal US was performed in 8 of these showing an excellent diagnostic relationship. On univariable analysis, factors significantly associated with VCP were prematurity, young age and lower weight at surgery and the presence of comorbidities. The presence of comorbidities and weight at surgery exhibited a significant risk of developing VCP postoperatively on multivariable analysis.
CONCLUSIONS
VCP is not an unusual complication of cardiovascular surgery. Certain factors were associated with VCP development but only the presence of comorbidities and weight at surgery were statistically significant on multivariable analysis. Flexible laryngoscopy is the standard diagnostic technique and laryngeal US appears to be a reliable complement.
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Affiliation(s)
- Enrique García-Torres
- Pediatric Cardiovascular Surgery Unit, Pediatric Institute of the Heart, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Juan L Antón-Pacheco
- Pediatric Airway Unit, Division of Pediatric Surgery, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
| | - Mª Carmen Luna-Paredes
- Pediatric Airway Unit, Division of Pediatrics, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
| | - Rocío Morante-Valverde
- Pediatric Airway Unit, Division of Pediatric Surgery, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
| | - Elena Ezquerra-Pozo
- Division of Pediatric Surgery, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
| | - Alicia Ferrer-Martínez
- Division of Pediatric Surgery, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
| | - Miguel A Villafruela
- Pediatric Airway Unit, Division of Otorhinolaryngology, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
| | - Ignacio Jiménez-Huerta
- Pediatric Airway Unit, Division of Otorhinolaryngology, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
| | - María López-Díaz
- Pediatric Airway Unit, Division of Pediatric Surgery, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
| | - Isabel Carrillo-Arroyo
- Division of Pediatric Surgery, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
| | - Lorenzo Boni
- Pediatric Cardiovascular Surgery Unit, Pediatric Institute of the Heart, Hospital Universitario 12 de Octubre, Madrid, Spain
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Rodney JP, Thompson JL, Anderson MP, Burkhart HM. Neonatal vocal fold motion impairment after complex aortic arch reconstruction: What should parents expect after diagnosis? Int J Pediatr Otorhinolaryngol 2019; 120:40-43. [PMID: 30753981 DOI: 10.1016/j.ijporl.2019.02.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 01/31/2019] [Accepted: 02/01/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVES To study the incidence, sequelae, follow up, and recovery rate of vocal fold motion impairment (VFMI) after complex aortic arch reconstruction in neonates. STUDY DESIGN Retrospective case control study. METHODS We retrospectively evaluated 105 neonates who underwent complex aortic arch reconstruction from 2014 to 2016. We compared patients that did have VFMI compared to a control group of patients with normal vocal fold movement. Descriptive statistics were computed for all demographic and clinical variables by treatment group. RESULTS 36% of patients were evaluated for VFMI (n = 38) by an otolaryngologist. The incidence of VFMI was 22% (n = 23). Females were more likely to have VFMI (p = 0.02). Aspiration was more common in patients with VFMI (p = 0.006). The difference in age, weight, incidence of pneumonia, nasogastric tube, gastrostomy, total length of stay, genetic anomaly, and reintubation was not significant between the VFMI group and control group (p > 0.05). Tracheostomy was not performed in any patients with unilateral paralysis. Only 61% of patients followed up in clinic (n = 14). 64% of patients showed improvement or resolution (n = 9). Average time to improvement was 4.8 months. Average time to complete resolution was 10.5 months. CONCLUSIONS VFMI after complex aortic arch reconstruction is relatively common. Despite increased aspiration in patients with VFMI, pneumonia did not occur at all in either group. Tracheostomy was not necessary in any patients with a unilateral paralysis. Most patients showed an improvement in the VFMI within 5 months of surgery. Our data support the need for otolaryngology follow-up after the diagnosis of VFMI.
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Affiliation(s)
- Jennifer P Rodney
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States.
| | - Jess L Thompson
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | - Michael P Anderson
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States; College of Public Health, Biostatistics and Epidemiology, United States
| | - Harold M Burkhart
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
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