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It is a simple bedside procedural examination that can be performed without sedation, during spontaneous breathing and with minimal risks. In some cases, it is dif fi cult to determine vocal fold movement because of patient move ment, secretions, or fl oppy laryngeal structures. Sometimes a vocal fold movement cannot be de fi nitively determined even by an experienced pediatric otolaryngolo gist. (45) In some instances, because of an incomplete view or concern for a secondary airway lesion, direct laryn goscopy with bronchoscopy under general anesthesia is required. This allows for evaluation of the more distal airway as well as palpation of the larynx to rule out other causes of vocal fold immobility such as posterior glottic stenosis or cricoarytenoid fi xation. It also allows for evaluation of other potential causes of dysphagia including laryngeal cleft and tracheoesophageal fi stula. However, under general anesthe sia the evaluation of vocal fold movement is limited and an experienced pediatric anesthesiologist is usually needed to achieve the correct plane of anesthesia. Secondary airway lesions are not uncommon in the setting of VFP. In a series of 102 pediatric patients, other airway lesions occurred in 45%, including laryngomalacia, tracheobronchomalacia, subglottic stenosis, intubationgran ulomas, cricoarytenoid joint fi xation, and laryngeal webs. (9) Isolated VFP will usually not cause persistent hypoxemia. If persistent hypoxemia occurs, other airway and pulmonary conditions should be ruled out.

Many otolaryngologists and pediatric cardiac surgeons recommend universal laryngoscopy screening of all infants after cardiac surgery because patients with VFP can be asymptomatic, but still contribute to subsequent breathing, feeding, and voice issues. (18) In a meta-analysis of infants who underwent PDA ligation, the reported incidence of VFP was always higher in studies in which universal postoper ative laryngoscopy was performed. (28) In a study in which all infants were screened with laryngoscopy after PDA ligation, 14% of infants with VFP were asymptomatic at the time of laryngoscopy. (26) Imaging In all infants with VFP without a clear cause, a cross sectional contrast-enhanced imaging study such as com puted tomography or magnetic resonance imaging should be performed to rule out a compressive mass lesion along the course of the vagus nerve or RLN. These images should include the brain, brainstem, neck, and chest. Alternatively, the chest component of the RLN course can be evaluated with radiography with further imaging if abnormal. Imag ing the head early in infants with BVFP is especially im portant because of the strong association between BVFP and CNS abnormalities. (9) VFP may be the only presenting sign of the intracranial abnormality. (46)(47)

TABLE 3. Advantages and Limitations of VFSS and FEES

VFSS

FEES

• Visualize all phases of swallowing (oral, pharyngeal, cervical esophageal) • Can correlate swallowing impairment with degree of aspiration

• Visualize nasal, pharyngeal, and laryngeal structures before and after swallowing • Evaluate structural components that may affect swallowing/ breathing/vocal quality • No contrast • Visualize secretion management, may detect aspiration from saliva • Evaluation of breastfeeding is possible • No radiation exposure

Advantages

• Attempts to mimic a typical feeding situation • Can evaluate bene fi t of therapeutic maneuvers

• Cooperation is needed • Radiation exposure

• Cooperation can be challenging

Limitations

• Minimally invasive, may be uncomfortable • Does not allow visualization during swallow • Potential risks (vasovagal reaction, bleeding, etc.)

• Limitations for positioning relative to equipment • Time constraints: samples swallowing brie fl y

• Requires contrast: alters taste

• Not appropriate if nasal obstruction

FEES ¼ fi beroptic endoscopic evaluation of swallowing; VFSS ¼ video fl uoroscopic swallow study. Adapted from Arvedson J, Brodsky L, Lefton-Greif MA. Pediatric Swallowing and Feeding: Assessment and Management. 3rd ed. San Diego, CA: Plural Publishing; 2020; and Arvedson JC. Assessment of pediatric dysphagia and feeding disorders: clinical and instrumental approaches. Dev Disabil Res Rev. 2008. doi:10.1002/ddrr.17.

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