xRead - February 2023

Neonatal Vocal Fold Paralysis

Marisa A. Ryan, MD, MPH,* Patrick A. Upchurch, MD, † Panayiota Senekki-Florent, PhD, CCC-SLP, BCS-S ‡ *Department of Otolaryngology – Head and Neck Surgery; † Department of Anesthesiology and Critical Care Medicine; and ‡ Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins University, Baltimore, MD

Practice Gaps Vocal fold paralysis (VFP) is a signi fi cant cause of airway and feeding compromise in infants. Both bilateral and unilateral VFP require evaluation with direct visualization and assessment of swallowing function. Many infants with bilateral VFP require interventions for both airway patency and swallowing. Some infants with unilateral VFP require respiratory and swallowing interventions. These infants need long-term monitoring to ensure that any related breathing, airway protection, or feeding issues are managed until they fully resolve. 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. Modi fi cation 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.

AUTHOR DISCLOSURE Drs Ryan, Upchurch, and Senekki-Florent have disclosed no fi nancial relationships relevant to this article. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device. ABBREVIATIONS BVFP bilateral vocal fold paralysis CNS central nervous system ECMO extracorporeal membrane oxygenation ELBW extremely low birthweight EMG electromyography FEES fi beroptic endoscopic evaluation of swallowing GERD gastroesophageal re fl ux disease OCEBM Oxford Centre for Evidence-Based Medicine PDA patent ductus arteriosus RLN recurrent laryngeal nerve SLP speech-language pathologist UVFP unilateral vocal fold paralysis VFP vocal fold paralysis VFSS video fl uoroscopic swallow study

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