Vocal Fold Paralysis
Marisa A. Earley, MD, and Max M. April, MD, FACS
Introduction/Etiology/Epidemiology
•Vocal fold paralysis in children is an uncommon and challenging problem.
•Vocal fold paralysis can be classified as unilateral vocal fold paralysis (UVFP) or bilateral vocal fold paralysis (BVFP).
—UVFP
▪The leading cause is iatrogenic after cardiac surgery (most commonly patent ductus arteriosus ligation), tracheoesophageal fistula repair, transcervical excision of branchial anomalies, or thyroidectomy.
▪Additional causes include trauma, intubation, cardiovascular anomalies, peripheral neurological disease, infection, and idiopathic origins.
▪Left-sided paralysis (Figure 12-1; see also Video 12-1 at https://www.aap.org/en-us/restricted/pediatric-pulmonology) is more common secondary to recurrent laryngeal nerve (RLN) having a longer course from the brainstem, through the neck, into the chest, and around the aortic arch on the left. The right RLN has a similar descent but travels around the right subclavian artery. Both nerves then ascend in the neck to innervate the larynx.
—BVFP
▪A neurological etiologic origin is encountered most frequently, with Arnold-Chiari malformation being the most common central nervous system cause.
▪Additional causes include idiopathic origins, followed by birth trauma (forceps, breach, or vertex delivery) and vincristine toxicity.
▪A more severe condition than UVFP, BVFP often requires intubation immediately after birth.
Clinical Features
•Stridor, with or without respiratory distress
—Stridor occurs in nearly all children with BVFP and 75% of children with UVFP.
—Airway obstruction that necessitates intervention is more common with BVFP.
•Dysphonia
—Dysphonia occurs in 50% of children with UVFP.
—It is less common in BVFP because the vocal folds are in the midline position, versus the paramedian position with UVFP.
—It may cause social, academic, and behavioral problems as children age.
—The child’s family may “get used to” the dysphonic voice, the child may not speak at the physician’s office, and children cannot articulate vocal concerns, which make this feature harder to diagnose.
•Feeding difficulty
—Occurs in 25% of children with UVFP
—Less common in BVFP unless secondary to underlying neurological disorder
•Aspiration
—Secondary to poor glottic closure and/or competency in UVFP
Differential Diagnosis
•Laryngomalacia
•Glottic web
•Vocal fold nodules, cysts, or other vocal fold lesions
•Cricoarytenoid joint fixation or subluxation
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