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TABLE 2. Relative Proportions of the Most Common Causes of Vocal Fold Paralysis in Infants

REFERENCE, NO. OF PATIENTS IATROGENIC, % IDIOPATHIC, % NEUROLOGIC, % BIRTH TRAUMA, % MISCELLANEOUS, %

Emery and Fearon (11), 71

35

23

31

7

4

Gentile et al (4), 22

18

27

27

23

5

Tucker, 30

20

–

50

10

20

Rosin et al (8), 51

29

24

35

6

6

de Gaudemar et al (10), 113

–

37

25

21

17

Zbar et al, 17

47

41

12

–

–

Daya et al (9), 102

43

16

35

5

1

Jabbour et al (12), 404

69

21

7

–

2

68 a

25 a

23

–

3

Jabbour et al (2017), 73

a These percentages add up to 119% because there was a group of patients (14/73, 19%) in this study with cardiac surgery/neurological disease as the etiology. These patients were counted in each group because the true etiology is unknown. (Adapted and updated from Table 1 in Benjamin JR, Goldberg RN, Malcolm WF. Neonatal vocal cord paralysis. NeoReviews . 2009. doi:10.1542/neo.10-10-e494.)

VFP from birth trauma is also attributed to stretch or compression of the RLN or vagus nerve and is associated with breech, vacuum, or forceps-assisted delivery. (9)(38) A systematic review found predominantly UVFP (64%) rather than BVFP in cases associated with birth trauma. (38) Chemotherapeutic regimens that contain vincristine, a vinca-alkaloid drug, have caused VFP because of peripheral neuropathy. (39) This is temporary and resolves after the vincristine has been stopped. (39) An endotracheal tube can compress the RLN between the thyroid cartilage and the arytenoid or cricoid cartilage, which can result in VFP. However, not all immobile vocal folds are the result of paralysis of the intrinsic laryngeal muscles. In some cases, the initial placement of either an endotracheal tube or a laryngeal mask airway can dislocate the arytenoid and lead to fi xation of the cricoarytenoid joint. In addition, prolonged intubation, especially in conjunction with a larger endotracheal tube, excessive patient movement, and uncon trolled gastroesophageal re fl ux disease (GERD), can result in posterior glottic stenosis. When this occurs, scarring at the posterior glottis or cricoarytenoid joint(s) can tether the vocal fold and prevent normal vocal fold movement even though innervation of the muscles is intact. If no other cause can be identi fi ed, then VFP is consid ered idiopathic. Idiopathic VFP can be either bilateral or unilateral. It has been proposed that increased activity in the adductor muscles of the larynx overpowers the abductor muscles and results in the immobile, paramedian position of the vocal fold(s). (40) Therefore, as the innervation and

proportion of VFP cases occurring after PDA ligation may increase. Noncardiac cardiothoracic surgeries can also be compli cated by VFP. It has been reported in 3% to 5.7% of pa tients after tracheoesophageal fi stula and esophageal atresia repairs. (32)(33)(34) The vagus nerve is also susceptible to injury during dissection along the carotid artery such as during extracorporeal membrane oxygenation (ECMO) can nulation. Although most cases of VFP from cardiothoracic surgery are left-sided, it is more commonly right-sided after ECMO cannula placement. (35) During the surgical dissec tion around the vagus nerve and RLN, transection of the nerves can occur, as can thermal, pressure, and tension injuries. Although transection will result in a permanent paralysis, other nerve injuries may have partial or complete recovery of vocal fold movement. Cardiac and mediastinal anomalies can be associated with VFP, even in the absence of a surgical intervention. In a series of infants and children with congenital BVFP, various associated cardiac anomalies were reported, includ ing 3 patients with ventricular septal defect, 2 with aortic coarctation, 2 with transposition of the great vessels, and 1 with an atrial septal defect. (16) An aberrant innominate artery in a child causing right-sided tracheal compression and a right-sided UVFP has also been reported. (9) Other thoracic anomalies associated with VFP include broncho genic cysts, esophageal duplication cysts, and cystic hy groma. (36)(37) These mediastinal anomalies are postulated to place stretch or compression on the RLN.

Vol. 21 No. 5

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MAY 20 20

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