Incidence and Recovery of Vocal Fold Immobility Following Pediatric Cardiac Operations

Abstract

Background: Loss of laryngeal function after congenital cardiac surgery causes morbidity and prolongs hospitalization. Early diagnosis of vocal fold immobility (VFI) and referral to pediatric otolaryngology (pOTO) aids in laryngeal rehabilitation. Understanding the incidence and recovery rates of VFI enables counseling for families of infants undergoing high-risk surgery. Methods: A retrospective chart review from November 2014 to July 2019 of infants postcardiac surgery where the aortic arch or surrounding structures were manipulated and were screened via flexible fiberoptic laryngoscopy (FFL) at a single institution was performed. Patients were divided into five surgical categories: Norwood procedure, aortic arch augmentation via median sternotomy, arterial switch operation, coarctation repair via lateral thoracotomy, and cardiac surgeries including ligation of a patent ductus arteriosus (PDA). Patients undergoing isolated PDA ligation were excluded. Results: One hundred ninety-nine qualifying operations occurred during this period; 28 patients did not undergo FFL before discharge and were excluded from the analysis. Immediately following cardiac surgery, 34% (58 of 171 patients) had VFI. Follow-up was completed by 38 of 58 patients with VFI. Complete recovery was demonstrated in 63% (24 of 38) of patients by 6 months and in 86% (33 of 38) within 18 months. The highest risk occurred with the Norwood procedure and arch augmentation via median sternotomy. Conclusions: Infants undergoing surgery involving the aortic arch and surrounding structures have high rates of VFI. Follow-up by pOTO is recommended to optimize laryngeal rehabilitation. Most patients have spontaneous recovery within 18 months of cardiac surgery.

Injection Laryngoplasty for Children with Dysphagia after Cardiac Surgery

“… 9 Studies of children with vocal cord immobility find that as many as 87.5% of patients will develop voice and swallowing dysfunction. 3 , 13 , 14 The dysphagia and aspiration risk can necessitate dietary modification, supplemental enteral feeds, or complete enteral feeds in 68.5% to 80.5% of children. 3 , 13 In this series, a nasogastric tube was placed in nearly all patients and dietary modification or NPO status was common.…”

“… 3 , 13 , 14 The dysphagia and aspiration risk can necessitate dietary modification, supplemental enteral feeds, or complete enteral feeds in 68.5% to 80.5% of children. 3 , 13 In this series, a nasogastric tube was placed in nearly all patients and dietary modification or NPO status was common. Consequently, this population of children after cardiac surgery will struggle frequently with swallowing that may be challenged by factors beyond just the vocal cords.…”

“…During cardiac surgery, especially with sternotomy, there is a recognized risk of iatrogenic injury to the recurrent laryngeal nerve that occurs in as many as 65% of procedures. 2 , 3 , 4 , 5 …”

Diagnostic Utility of Point-of-Care Ultrasound in the Pediatric Cardiac Intensive Care Unit

“…Vocal cord immobility or paralysis is a known complication following pediatric cardiac surgery. The incidence of vocal cord immobility can be as high as ~ 35% after aortic arch repairs in children [96]. The gold standard to evaluate vocal cord function is flexible nasolaryngoscopy, which is invasive and can be uncomfortable, especially in unsedated patients.…”

“…Vocal cord immobility prolongs hospitalizations in children following cardiac surgery [96]. The risk of aspiration is notably higher in children with vocal cord immobility, so the sooner the diagnosis is made, the sooner the patient can be screened for aspiration which may then alter their management and discharge plan, including the long-term feeding method [101].…”