Vocal cord paralysis in children

Bilateral vocal cord paralysis is a common cause of stridor in infants and children. There are significant differences in this entity between children and adults with regard to etiology, diagnosis, management, and outcome. A review of 10 years' experience at Children's Hospital of Philadelphia identified 51 children seen with the diagnosis of vocal cord paralysis. These cases were evaluated with respect to etiology of paralysis, whether unilateral or bilateral, delay in diagnosis, need for tracheotomy, abnormality of voice, surgical treatment, and outcome. Guidelines for management for a child with vocal cord paralysis are presented with emphasis on flexible endoscopic evaluation and conservative management.     

Vocal cord paralysis in infants and children

Vocal cord paralysis is the second most common cause of neonatal stridor. Recognition of laryngeal paralysis warrants further evaluation for an underlying etiology as it is frequently a manifestation of a multisystem anomaly. Initial intervention must concentrate on airway stabilization and treatment of any underlying conditions. Management strategies should be individualized and focus on maintenance of a safe and stable airway, acquisition of intelligible speech, and deglutition without aspiration.     

Vocal cord abnormalities in children with velopharyngeal valving problems

Twenty-seven subjects with borderline velopharyngeal valving mechanisms diagnosed as having hoarseness with or without vocal cord pathology participated in a follow-up study. The mean age of the subjects was 13 years, two months, and they were recalled an average of 4.7 years following initial study. The reassessment protocol included an evaluation of speech, velopharyngeal valving, behavioral and health histories, and laryngoscopy. Upon follow-up, 70 percent of the subjects retained vocal cord abnormalities. The eight subjects who had normal cords continued to demonstrate hoarse voice quality. Only 53 percent of the subjects who retained some atypical condition of the cords showed the same condition upon re-evaluation. In each case, the condition retained was vocal cord nodules. The subjects who no longer showed vocal cord pathology had an average age of 15 years, eight months, as opposed to an average of 12 years, one month for those children who retained abnormalities. This difference was significant, indicating that age was an important factor in remission. Surgical removal of vocal cord nodules without attention to improving the velopharyngeal valving mechanism proved to be an ineffective approach to management; however, improvement in valving mechanism was usually associated with improvement in the vocal cord condition although it did not always eliminate it. None of the subjects in this study demonstrated an unequivocally adequate velopharyngeal valving mechanism. This was true even in the group of subjects who retained hoarseness but lost vocal cord pathology. The study suggests that careful differential diagnosis is essential in the management of these laryngeal problems which are perhaps the result of laryngeal modification compensatory to poor velopharyngeal valving mechanisms. Investigations of laryngeal anatomy and physiology and study of functional correlates to both hoarseness and vocal cord pathology in these patients, is essential.     

Vocal cord sulcus

Vocal cord sulcus is a congenital condition consisting of a furrow on the medial edge of the vocal cord. It is most often bilateral but may be unilateral. The symptoms are a hoarse and breathy voice due to incomplete closure of the vocal cords. The present series comprises 15 patients found among 1,400 patients with voice and speech disorders. The condition is often overlooked and regarded as part of a primary functional hyperkinetic voice disorder. By close inspection the furrow can often be seen by indirect laryngoscopy. In many cases, however, microlaryngoscopy under general anaesthesia should be performed, but the furrow is only detected if a search is made for it. The condition is often found in younger patients, probably due to the fact that the sulcus is difficult to detect in older patients who have developed severe organic changes in a effort to overcome the incomplete closure of the glottis.     

Vocal cord paralysis

The information presented in this article demonstrates that unilateral or bilateral vocal cord paresis or paralysis in infants and children is difficult to diagnose and difficult to manage. In an attempt to provide the otolaryngologist with a concise set of relevant guidelines, the following rules for management are presented here. 1. Suspect bilateral abductor vocal cord paralysis (BAVP) when a neonate or infant presents with high-pitched inspiratory stridor and evidence of airway compromise. Factors that should increase the suspicion of BAVP include associated Arnold-Chiari malformation; congenital anatomic abnormality involving the mediastinum (for example, tracheoesophageal fistula, vascular ring, other vascular anomalies); dysmorphic syndromes, especially those involving brainstem dysfunction; and manifest findings indicative of neuromuscular disorder. The neonate or infant with Arnold-Chiari malformation and inspiratory stridor has bilateral abductor vocal cord paralysis until proven otherwise. 2. Suspect unilateral vocal cord paresis or paralysis in an infant or child with hoarse voice, low-pitched cry, or breathy cry or voice. The infant who develops mild stridor and hoarse cry following surgical repair of a patent ductus arteriosus or tracheoesophageal fistula has a unilateral vocal cord paralysis until proven otherwise. 3. Direct laryngoscopy with the flexible fiberoptic nasopharyngolaryngoscope and photodocumentation using a videocassette recorder offers the best method for diagnosis of vocal cord paresis or paralysis. Additional diagnostic studies that may be helpful include radiographic studies, CT scan, MRI scan, electromyography of the larynx, and, in older children, stroboscopy. 4. In using a flexible direct laryngoscope be careful not to interpret all motions of the vocal cords or arytenoids as evidence to preclude the diagnosis of vocal cord paralysis or paresis and be careful not to mistake the anterior intraluminal portion of a normal cricoid for an "anterior glottic web." 5. Tracheotomy is often required in order to assure adequate airway during infancy for children with BAVP. However, with the advent of sophisticated cardiorespiratory monitoring equipment and methods for monitoring blood oxygen and carbon dioxide levels, tracheotomy can be delayed until attempts have been made to improve the adequacy of the airway with neurosurgical intervention or other procedures.(ABSTRACT TRUNCATED AT 400 WORDS)     

Vocal cord paralysis in postpoliomyelitis syndrome

Postpoliomyelitis syndrome is characterized by new neuromuscular symptoms, including weakness, developing years after recovery from acute polio. Bilateral vocal cord paralysis is presented as a new manifestation of this syndrome. Other clinical features of post-poliomyelitis syndrome in this report are discussed. The etiology of this syndrome is unknown, though attrition or immune-mediated destruction of collateral muscular innervation appears likely. The pathologic findings include scattered individual muscle fiber atrophy as well as evidence of chronic denervation and reinnervation. This form of motor deterioration is not life-threatening, but potentially may cause increasing disability in a large number of polio survivors. Proper supportive care of facial, laryngeal, and pharyngeal weakness is crucial in the management of these patients.     

Vocal nodules in children

We reviewed 27 pediatric patients who had vocal nodules removed surgically in a 5-year period. Age of operation, duration of symptoms, indications for operation, and the results of removal are analyzed. The techniques of laryngoscopic assessment with telescopes and of microsurgical removal are described in detail. The 27 children had 53 nodules removed. Almost all had normal or improved voices as judged by the parents' answers to a written questionnaire. From the results of this series, microsurgical removal of vocal nodules in children is justified in selected patients.     

Vocal cord adduction while sniffing

The movement of vocal cords while sniffing was observed by fiberscope and electromyogram. Nasal airflow rate was compared while sniffing and during normal respiration. Fiberscopic and electromyographic observations revealed that the vocal cords adduct while the subject is sniffing. The olfactory sense was not needed. It also was different from the defensive laryngeal reflex closure. The nasal airflow rate during sniffing was less during inspiration than during normal respiration. Inhalation while sniffing was different from that of respiration. It is concluded that the vocal cords adduct while sniffing, and that the nasal airflow rate might be less during sniffing than during normal respiration.     

Vocal cord injection techniques.

Injection techniques for the rehabilitation of paralytic dysphonia (e.g., Teflon) remain popular in the United States. This article presents a historical perspective of vocal cord paralysis, its work-up, and the indication, timing, techniques, and results of vocal cord injection.