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Clinical Review & Education Review

Pediatric Unilateral Vocal Cord Paralysis

Table 2. Studies Reporting on Thyroplasty for Pediatric UVCP

Results

Anesthesia or Airway Management GA tracheostomy

Level of Evidence/ Risk of Bias Age, y UVCP Origin

Source (No. of Patients)

Glottic Closure

Adverse Events

Time to Surgery, y Indication

Dysphonia

Swallow

Isaacson, 18 1990 (1)

None

Deteriorated at 6 mo

Increase in glottic gap at 6 mo

4/5

14 Neurologic

Aphonia and aspiration

Link et al, 19 1999 (6)

4/5

17 Idiopathic 14 Congenital 12 Cardiac surgery 14 Skull base tumor 14 Skull base tumor

Dysphonia Local Dysphonia Local

Resolved

Improvement NA

No improvement No improvement No improvement

Improvement

Dysphonia and aspiration

Local

Improvement

2 Cardiac surgery 8 Thoracic surgery

Resolved

Gardner et al, 20 2000 (2)

LMA

Improvement Resolved

None

4/5

6.5

Dysphonia and aspiration

4 PDA

Dysphonia LMA

Improvement NA

Full closure

None

ligation

Daya et al, 1 2000 (1)

Dysphonia NA

No improvement

4/5

3 Tracheo-

esophageal fistula repair

Sipp et al, 16 2007 (2)

LMA

Resolved

None

4/5

5.5 Thoracic surgery

Dysphonia and aspiration Dysphonia and aspiration

Local

Resolved

Aspiration pneumonia and 7 days of intubation

18 Neurologic

Abbreviations: GA, general anesthesia; LMA, laryngeal mask airway; NA, not applicable or stated; PDA, patent ductus arteriosus; UVCP, unilateral vocal cord paralysis.

and another patient improved at 5 months postoperatively. Zur 23 reported resolution of glottic closure in 7 of 7 patients examined 6 months postoperatively. Finally, Marcum et al 9 reported improve- ment at 7 months postoperatively. Overall, it seems that most pa- tients will experience symptomatic improvement between 3 and 7 months. Discussion Our report indicates the scarcity of objective data on surgical inter- ventions for pediatric UVCP. We found 15 English-language studies reporting information on surgical interventions in 84 patients with UVCP. This report highlights the conclusion that surgical interven- tion for children with UVCP is guided by level 4 evidence. In our re- port, 13 of 16 studies received the highest risk of bias score (Tables 1, 2,and3).Thescarcityofdataissomewhatexpectedgiventhatsymp- tomatic UVCP is relatively infrequent in a pediatric population. 25 A key issue that remains controversial in the management of UVCP is the timing of surgical intervention. In adult patients, laryn- geal EMG can be used as an adjunct for prognostication and decid- ing on the timing of permanent intervention. Currently, there are no EMG-validated studies in pediatric patients 24 ; hence, the timing of intervention should be guided by symptom severity, knowledge of UVCP natural history, and the effect of dysphonia on the child. A study of 404 children by Jabbour et al 2 provides insights into the naturalhistoryofpediatricvocalcordparalysis.Theauthorsnotethat, for unilateral and bilateral vocal cord paralysis, approximately half

(45.8%) of the children achieve symptomatic recovery. Signifi- cantly, both the time to symptom resolution and the rate of symp- tom resolution had statistically significant variations based on the vocal cord paralysis. Children with vocal cord paralysis attributable to cardiac surgery or of neurologic origin achieved lower rates of vo- cal cordmovement recovery (24%and 27%, respectively) than chil- dren with idiopathic vocal cord paralysis (40%). In addition, chil- dren with vocal cord immobility attributable to cardiac surgery or of neurologic origin had a shorter mean time to resolution of symp- toms (6.3 and 9.9 months, respectively) than the idiopathic group (11.1 months). The longest time from diagnosis to spontaneous re- covery of vocal cord movement in any category of patients was 38 months. 2 Children who experience aspiration due to UVCP should be of- fered at least a temporary surgical intervention, such as tracheos- tomy or injectionmedialization. However, most childrenwithUVCP experiencedysphonia as theirmain symptom, 2 and it is currentlyun- clear when to offer surgery for these patients. Literature on the ef- fect of dysphonia on children is limited. One study 8 suggests that childrenasyoungas6yearsexperienceconcernoverdysphonia.Dys- phonia was found to have a negative effect on the lives of children across the domains of physical, social or functional, and emotional performance. This negative effect became more pronounced with age. Given that UVCP was mostly diagnosed close to birth in children, 2 a logical algorithmfor treatment of dysphoniawould con- sistofconservativeand/ortemporarymeasuresforthefirstfewyears after diagnosis until the possibility of spontaneous recovery ismini- mized. After observation and ideally before 6 years of age, a more

JAMA Otolaryngology–Head & Neck Surgery July 2015 Volume 141, Number 7 (Reprinted)

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