Congenital Bilateral Adductor Vocal Cord Paralysis

Bilateral Vocal Fold Abduction Dysfunction: A Report of Two Neonatal Cases

Stridor is caused by oscillation of the narrowed upper airway. The most common cause of neonatal stridor is laryngomalacia, followed by vocal fold abduction dysfunction. Herein, we present two neonatal cases of idiopathic dysfunction of vocal fold abduction. A neonate was admitted to the neonatal intensive care unit (NICU) on day 4 of life for inspiratory stridor, intermittent subcostal retraction, and cyanosis. A second neonate was admitted to the NICU on day 7 of life for inspiratory stridor and cyanosis when crying. Neither patient had dysmorphic features or unusual cardiac ultrasonography findings. The diagnosis was confirmed by laryngo-bronchoscopy. Conservative treatment with biphasic positive airway pressure was effective in both cases and symptoms resolved within a few months. Resolution of vocal fold abduction dysfunction was confirmed by repeat endoscopy. Clinical manifestations of vocal fold abduction dysfunction vary widely. Although most cases resolve spontaneously, prolonged tube feeding, or even tracheostomy, is needed in some severe cases. Diagnosis of vocal fold abduction dysfunction requires a laryngo-bronchoscopy study; thus, there may be a large number of undiagnosed patients. Vocal fold abduction dysfunction should be considered in the differential diagnosis for neonatal inspiratory stridor.

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.

Congenital Bilateral Vocal Cord Paralysis and the Role of Glycine

Objectives:

We sought to modify normal laryngeal constrictor (LC) motoneuron activity to induce a pattern of aberrant LC muscle function that may serve as a model of congenital bilateral vocal cord paralysis.

Methods:

Single unit extracellular recordings of functionally identified LC motoneurons were made in anesthetized Sprague-Dawley rats, and the response to both intravenous and iontophoretic application of the glycine antagonist strychnine was studied.

Results:

The postinspiratory firing pattern of LC motoneurons became inspiratory after intravenous injection of strychnine (4 of 5 rats), but no change was recorded in response to strychnine iontophoresis (7 of 8 rats).

Conclusions:

Blockade of glycinergic inhibitory neurotransmission by strychnine, acting above the level of the LC motoneuron, causes LC motoneurons to fire during inspiration rather than after inspiration. This observation suggests that impaired glycine neurotransmission may be an underlying mechanism that explains the clinical manifestations of congenital bilateral vocal cord paralysis.

Familial congenital bilateral vocal fold paralysis: a novel gene translocation

OBJECTIVES

True vocal fold (TVF) paralysis is a common cause of neonatal stridor and airway obstruction, though bilateral TVF paralysis is seen less frequently. Rare cases of familial congenital TVF paralysis have been described with implied genetic origin, but few genetic abnormalities have been discovered to date. The purpose of this study is to describe a novel chromosomal translocation responsible for congenital bilateral TVF immobility.

METHODS

The charts of three patients were retrospectively reviewed: a 35 year-old woman and her two children. The mother had bilateral TVF paralysis at birth requiring tracheotomy. Her oldest child had a similar presentation at birth and also required tracheotomy, while the younger child had laryngomalacia without TVF paralysis. Standard karyotype analysis was done using samples from all three patients and the parents of the mother, to assess whether a chromosomal abnormality was responsible.

RESULTS

Karyotype analysis revealed the same balanced translocation between chromosomes 5 and 14, t(5;14) (p15.3, q11.2) in the mother and her two daughters. No other genetic abnormalities were identified. Neither maternal grandparent had the translocation, which appeared to be a spontaneous mutation in the mother with autosomal dominant inheritance and variable penetrance.

CONCLUSIONS

A novel chromosomal translocation was identified that appears to be responsible for familial congenital bilateral TVF paralysis. While there are other reports of genetic abnormalities responsible for this condition, we believe this is the first describing this particular translocation.

Acquired bilateral adductor laryngeal paralysis in neonates and children: a case series and a systematic review

OBJECTIVES

To present a series of acquired bilateral adductor laryngeal paralysis (BAdLP) and review the literature on clinical manifestations and management.

METHODS

A retrospective review of a single tertiary care practice of pediatric otolaryngology was conducted. Patients were identified from a surgical database spanning twelve years of practice (2002-2013). The variables documented included gender, age at presentation, co-morbid conditions, documented laryngeal findings on endoscopy, management and outcome. A systematic review of the literature was conducted to identify reports on BAdLP in children and associated conditions.

RESULTS

Five cases (four girls and one boy) ranging from 3 months to 16 years of age were identified. All cases were documented using rigid and/or flexible laryngoscopy. In four cases, the onset was after major cardiac surgery complicated by cerebral vascular accidents, while one followed a thalamic stroke. Four were managed with tube feeding. Only three papers reported BAdLP in children.

CONCLUSIONS

The cases identified were all acquired after a central neurological insult. The profile is distinct from the congenital adductor form of laryngeal paralysis previously described. However, the symptom complex is identical. We believe this is the largest case series from one center to be reported.

Magnetic Resonance Imaging Findings in Pediatric Bilateral Vocal Fold Dysfunction

Objectives:

We studied the findings of brain magnetic resonance imaging (MRI) in infants with idiopathic congenital bilateral vocal fold dysfunction (CBVFD).

Methods:

We performed a retrospective investigation of a case series.

Results:

We identified 26 children (14 male, 12 female) over 11 years. Three children were excluded. Thirteen patients required airway interventions, including continuous positive airway pressure (4 patients), endotracheal intubation (1), and tracheostomy (8). The findings on brain MRI were abnormal in 8 patients (35%). Tracheostomy was required in 3 patients (38%) with abnormal MRI findings, as compared with 5 of 15 patients (33%) with normal MRI findings. The MRI abnormalities involved evidence of white matter injury (2), abnormal white matter signal (1), subdural blood (3), cerebral swelling (1), and perisylvian polymicrogyria (1). The cranial ultrasound findings were abnormal in 4 of 11 patients. The MRI findings were abnormal in 2 of 7 children in whom the cranial ultrasound findings were normal, and in 2 of the 4 patients in whom the cranial ultrasound findings were abnormal.

Conclusions:

The MRI abnormalities were nonspecific; however, they may indicate unrecognized perinatal intracranial injury as being related to CBVFD. In addition, MRI may reveal an underlying structural brain anomaly. Cranial ultrasound has poor sensitivity and specificity. Hence, MRI should be considered as part of the routine assessment of neonates with CBVFD.

Paediatric vocal fold paralysis

INTRODUCTION AND OBJECTIVES

Vocal fold paralysis (VFP) is a relatively common cause of stridor and dysphonia in the paediatric population. This report summarises our experience with VFP in the paediatric age group.

METHODS

All patients presenting with vocal fold paralysis over a 12-month period were included. Medical charts were revised retrospectively. The diagnosis was performed by flexible endoscopic examination. The cases were evaluated with respect to aetiology of the paralysis, presenting symptoms, delay in diagnosis, affected side, vocal fold position, need for surgical treatment and outcome.

RESULTS

The presenting symptoms were stridor and dysphonia. Iatrogenic causes formed the largest group, followed by idiopathic, neurological and obstetric VFP. Unilateral paralysis was found in most cases. The median value for delay in diagnosis was 1 month and it was significantly higher in the iatrogenic group. Surgical treatment was not necessary in most part of cases.

CONCLUSIONS

The diagnosis of VFP may be suspected based on the patient's symptoms and confirmed by flexible endoscopy. Infants who develop stridor or dysphonia following a surgical procedure have to be examined without delay. The surgeon has to keep in mind that there is a possibility of late spontaneous recovery or compensation.

A case of Moebius syndrome presenting with congenital bilateral vocal cord paralysis

We describe a female infant with bilateral facial paralysis and abducens palsy. To the best of our knowledge, this is the first report of Moebius syndrome presenting with congenital bilateral vocal cord paralysis (CBVCP). Although CBVCP can be part of a recognizable syndrome, i.e. Down syndrome, 22q deletion syndrome, Robinow's syndrome and cerebro-oculo-facio-skeletal syndrome, no reports of Moebius syndrome with CBVCP were found in the literature. CBVCP is often associated with central nervous system abnormalities. However, our patient had no detectable brain abnormalities. The etiology of Moebius syndrome remains unknown. It is interesting that the clinical manifestations of Moebius syndrome can include CBVCP. However, the pathophysiology of CBVCP is unknown and further investigations into the etiology of Moebius syndrome are required.