xRead - February 2023

Objectives After completing this article, readers should be able to:

1. Recognize the risk factors and presentation of neonatal vocal fold paralysis. 2. Describe the evaluation and management of the neonatal airway and swallowing issues in the setting of vocal fold paralysis.

INTRODUCTION

injury or lesion anywhere that impinges on the vagus nerve or RLN. The motor neurons of the vagus nerve (cranial nerve X) originate in the nucleus ambiguus in the medulla of the

Vocal fold paralysis (VFP) occurs because of dysfunction of the motor nerve supply of the larynx from the vagus nerves via the recurrent laryngeal nerves (RLNs). The RLNs innervate the intrinsic muscles of the larynx that are responsible for both adduction and abduction of the vocal folds.

TABLE 1. Causes of Neonatal Vocal Fold Paralysis

Central nervous system lesions • Arnold-Chiari malformation (16) • Cerebral agenesis (16) • Hypoxic-ischemic encephalopathy (103)

EPIDEMIOLOGY OF NEONATAL VFP

VFP accounts for 10% of congenital laryngeal anomalies and is the second most common cause of neonatal stridor, behind laryngomalacia. (1)(2) The overall incidence of VFP in infants is unknown. However, in a recent study of preterm infants in a NICU, 3.5% were diagnosed with VFP and this increased to 18% when birth gestational age was less than 26 weeks. (3) This study also identi fi ed an asso ciation between VFP and black race. No other associations with race or ethnicity have been reported. Several case series indicate a slight male predominance, (4)(5)(6)(7) but at least 1 review found a female predominance. (8) Several studies report a slight predominance of bilateral VFP (BVFP), (4)(6)(8) whereas others have found a predominance of unilateral VFP (UVFP). (5)(9)(10)(11)(12) UVFP is usually left-sided. (3)(5)(6)(8)(9)(10)(11)(12) An association between neonatal VFP and several syndromes has been reported including trisomy 21, CHARGE (coloboma, heart defects, choanal atresia, growth restriction, genital abnormalities, and ear abnormalities) syndrome, 22q11 deletion syndrome, Robinow syndrome, cerebro-oculofacioskeletal syndrome, Moebius syndrome, Pierre-Robin sequence, and Charcot Marie-Tooth disease. (6)(8)(13)(14)(15)(16)

• Intraventricular hemorrhage (37) • Subdural hemorrhage (46)(47) • Stroke (104) • Intracranial or skull base mass B Neuro fi bromatosis, meningomyelocele, encephalocele, etc (2)(16) • Hydrocephalus (2)(16) Iatrogenic injury during cardiac, thoracic, or neck surgery • Ligation of patent ductus arteriosus (28) • Aortic arch reconstruction (83) • Tracheoesophageal fi stula and esophageal atresia repair (32)(33) • Resection of neck mass (105) • Extracorporeal membrane oxygenation cannulation of neck vessels (35)(83) • Central line placement (106) Mediastinal or chest anomalies • Masses (36)(37) • Vascular rings/anomalies (9)(107) Birth trauma (38)

Peripheral neurotoxicity from vincristine (39) Direct pressure from endotracheal tube (108) Idiopathic (55)

ETIOLOGY

Neonatal VFP can be congenital or acquired after birth. The causes (Table 1) are varied and can occur from an

Vol. 21 No. 5

MAY 20 20 e309

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