Paradoxical vocal cord movement in newborn and congenital idiopathic vocal cord paralysis: two of a kind?

The second most common cause of stridor reported in the newborn is bilateral vocal cord paralysis (BVCP) and one-third of the cases have been categorized as idiopathic. During the last year four children with stridor since birth were referred to our department for examination. Videotaped flexible laryngoscopy, carried out with the patient awake or under general anaesthesia with a spontanous respiration, revealed instead of abduction of the vocal cords during inspiration, rather an active adductory movement. Consequently instead of BVCP, we made the diagnosis paradoxical vocal cord movement (PVCM). One of the twins required a tracheostomy, the three other patients have been observed without the need of further treatment. No previous publications have described PVCM in newborn. However, our observations and video recordings clearly show that the stridor in our four patients is due to PVCM. This is possibly the same condition as earlier reported as congenital, idiopathic BVCP where incoordinated vocal cord movement or dyskinesia has been a part of the laryngoscopic findings. The mechanism behind PVCM in this age group or site of lesion is unclear.     

Congenital laryngeal stridor

We reviewed the diagnosis, complications and treatment of congenital laryngeal stridor (CLS), in 97 patients who consulted our clinic between 1991 and 2001. The 97 patients were diagnosed with laryngeal malacia (32%), vocal cord paralysis and laryngeal stenosis (22%), a neoplastic disease like hemagioma and papilloma (11%), or cystic disease (7%). The cases with vocal cord paralysis, laryngeal stenosis or laryngeal cysts were usually diagnosed within 2 months of birth based on severe dyspnea. Two of the 31 cases of laryngeal malacia and 2 of the 22 cases of vocal cord paralysis were associated with neuromuscular disorders. Three patients suffered from vocal cord paralysis complicated by laryngeal stenosis. Thirty-three of the 97 cases required a tracheostomy; these 33 cases included the one case of laryngeal papilloma (100%), 9 of the 10 cases of hemangioma (90%), and 18 of the 24 cases of laryngeal stenosis (75%). Since any disorders of the upper airway can potentially induce stridor, establishing an accurate diagnosis is sometimes difficult when stridor is the only presenting symptom. Hence, information on associated symptoms and the past history of the subject is particularly important for an accurate diagnosis. In addition, decisions regarding the course of treatment course require adequate consideration of possible complications.     

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)     

新生儿双侧声带麻痹临床特点及预后分析

目的 探讨新生儿双侧声带麻痹的病因、临床特点、治疗及预后转归。 方法 对新生儿中心在2016年1月至2020年12月期间收治的双侧声带麻痹患儿进行回顾性分析,记录患儿的基本资料、病因、治疗情况及预后情况,并对患儿进行门诊及电话随访。 结果 共纳入28例患儿,男18例,女10例,年龄1~24 d,中位年龄3.5 d。92.9%(26/28)的患儿为足月儿,53.6%(15/28)的患儿为剖宫产。患儿首发症状主要为吸气性喉鸣及呼吸困难,占比高达78.6%(22/28),其次为呛奶及呕吐,占比为14.3%(4/28)。先天性双侧声带麻痹23例(82.1%,23/28),其中合并中枢神经系统病变7例(23.8%),先天性心脏病6例(21.4%),喉气管疾病6例(21.4%),胃食管反流疾病2例(7.1%);后天获得性声带麻痹5例(17.9%,5/28),获得性因素中多发于食管、气管疾病术后(80%,4/5)。全部患儿中8例(28.6%)行气管切开。所有患儿随访时间1个月~4年,死亡4例。气管切开患儿8例中,1例12个月时顺利拔管,1例堵管中,余5例目前随访16~47个月声带仍无恢复。观察等待20例患儿中,11例(64.7%)在后期随访的1~38个月内痊愈,声带活动恢复,6例(35.3%)在后期随访的5~17个月内声带活动改善,活动后喉鸣。 结论 新生儿双侧声带麻痹病因以先天性多见,共患病因素多,临床多表现为喉鸣及呼吸困难,部分有吞咽困难。气管切开术在新生儿双侧声带麻痹中并不是普遍必要的,多数先天性双侧声带麻痹患儿可自行恢复,预后较好,不要过早行外科手术干预。     

Endoscopic percutaneous suture lateralization with syringe needles for neonatal bilateral vocal cord paralysis

ObjectiveTo explore the novel technique of percutaneous endoscopic suture lateralization for bilateral vocal cord paralysis (BVCP) in neonates from Shenzhen, China, and to evaluate the safety and efficacy of the operation.MethodsIn this retrospective case series, we present four neonates with BVCP diagnosed within 3 days after birth from Shenzhen Children's Hospital. All had stridor, respiratory distress and hypoxemia requiring respiratory support at diagnosis. Endoscopic vocal fold lateralization was performed under general anesthesia using 3.0 mm endotracheal intubation through the improved technique of percutaneous needle-directed placement of a 4–0 Prolene suture, without the use of specialized equipment. A 4–0 Prolene wire was led out through two 10 ml syringe needles, the left vocal cord was fully moved and fixed under the skin with endoscopy monitoring.ResultsOverall, 3/4 of the patients showed clinical improvement in stridor and dyspnea 2–3 weeks after the operation and avoided a tracheostomy, two of them could breathe and feed normally when they were discharged from hospital, and one patient had a weak ability to suck but could breathe normally. The last patient had to undergo a tracheotomy due to the poor improvement in respiratory distress. None of the babies experienced any complications from this surgery, but case four presented with a series of complications and other problems in postoperative care related to the tracheostomy. At the last follow-up (mean 8 months), complete function of the bilateral vocal cords was acquired in case two (6 months) and partial function of the vocal cords was acquired in case one (13 months), with the other cases still experiencing paralysis.ConclusionEndoscopic percutaneous suture lateralization may be a reversible, effective and minimally invasive primary treatment for neonatal BVCP. Most of neonates with BVCP undergoing this procedure avoided a tracheotomy.     

支撑喉镜下CO2激光杓状软骨切除术治疗双声带外展麻痹

目的　探讨支撑喉镜下CO2 激光显微杓状软骨切除术治疗双声带外展麻痹的手术方法、疗效和适应证。方法　 1994～ 1998年收治双声带外展麻痹患者 8例 ,其中 3例曾在外院经颈外进路手术失败 ,全部术前行气管切开术。参照并改良Ossoff窥镜下杓状软骨切除术 ,汽化杓状软骨前部 ,包括声带突和部分肌突 ,一小部分室带及声带后端 ,保留粘软骨膜并缝合切口 ,以消灭创面 ,双侧分次手术。结果　术后无肉芽滋生 ,无误吸 ,保留发音功能。 5例拔管 ,2例日间堵管、因睡眠时喉鸣未予拔管 ,1例等待对侧手术。随诊 6个月～ 3 5年。结论　本方式弥补了单纯窥镜及外科手术不足 ,如粘膜出血、水肿、操作困难等 ,而具备显微外科精细、准确的特点。术后反应轻微 ,保留发音功能。并可作为杓状软骨切除术或神经再支配手术失败后的补充手术     

儿童双侧声带麻痹诊治的现状与进展

双侧声带麻痹(BVCP)是指双侧支配咽喉部肌肉运动的神经传导通路受损引起的双侧声带运动障碍,占儿童先天性喉部异常疾病的第二位。主要症状为上气道梗阻、喘鸣、声音嘶哑等。其病因包括神经性、医源性、特发性及其他病因。临床可行病因评估、声带运动振动评估、影像学检查、喉肌电图及喉超声等检查评估。缓解呼吸道阻塞为治疗的主要目的,恢复喉的生理功能为治疗的最终目标。治疗方法有无创正压通气、气管切开术、环状软骨裂开术、杓状软骨切除术、声带后端切断术、声带外移固定术、选择性喉神经修复术、肉毒杆菌毒素注射喉内肌及其他新兴治疗方法。     

颈侧进路内镜下喉外单侧杓状软骨次全切除术治疗双侧外展性声带麻痹

目的：探讨提高治疗双侧外展性声带麻痹疗效的手术方法。方法：对13例双侧外展性声带麻痹伴呼吸困难的患者，行气管切开插管、全麻，经颈侧进路内镜下实施喉外单侧杓状软骨次全切除术。结果：手术过程均顺利，术后均未放置扩张子；呼吸和发声功能均恢复满意；拔管时间为8～15d，平均11．5d；术后随访6～36个月，未出现再狭窄、发声质量下降及呼吸困难等并发症。结论：该手术操作简单，术中对声门裂的可控性好，对喉黏膜无损伤，无需放置喉内扩张子；术后喉功能恢复快而满意，是治疗双侧外展性声带麻痹的较好术式。     

支撑喉镜下CO2激光杓状软骨切除术治疗双声带外展麻痹

目的 探讨支撑喉镜下ＣＯ２激光显微杓状软骨切除术治疗双声带外展麻痹的手术方法、疗效和适应证。方法１９９４￣１９９８年收治双声带外展麻痹患者８例,其中３例曾在外院经颈外进路手术失败,全部术前行气管切开术。参照并改良Ｏｓｓｏｆｆ窥镜下杓状软骨切除术,汽化杓状软骨前部,包括声带突和部分肌突,一小部分室带及声带后端,保留粘软骨膜并缝合切口,以消灭创面,双侧分次手术。结果 术后无肉芽滋生,无误吸,保留发音功     

喉返神经修复术及非喉返神经修复术治疗声带麻痹

目的 探讨喉返神经修复术及非喉返神经修复术这两种不同术式治疗声带麻痹的疗效。方法 ①单侧声带麻痹21例, 其中采用喉返神经修复术(喉返神经减压术、颈袢神经与喉返神经吻合术、颈袢神经肌肉蒂环杓侧肌移植术)15例, 采用非喉返神经修复术(声带自体脂肪注射术、自体软骨Ⅰ型甲状软骨成形术)6例;②双侧声带麻痹16例, 其中采用喉返神经修复术(喉返神经减压术、颈袢神经肌肉蒂环杓后肌移植术)6例, 采用非喉返神经修复术(声带外移术、内镜下杓状软骨切除术)10例。治疗前后以电子喉镜、频闪喉镜、声音评估等评价手术疗效。结果 ①单侧喉返神经麻痹患者中喉返神经修复组15例, 术后术侧声带活动不同程度改善, 发音时声带突明显内收, 声带振动及黏膜波均恢复对称性, 声门闭合良好, 手术前后的最大声时为(5.51±1.05)s和(12.10±1.41)s, 差异有统计学意义(P<0.01);非喉返神经修复术术后声带均不同程度内移, 声嘶症状改善, 但声带均无运动, 手术前后的最大声时为(5.47±0.45)s和(11.83±1.47)s, 差异有统计学意义(P<0.01)。神经修复组和非神经修复组术后最大声时比较, 差异无显著性意义(P>0.05);②双侧喉返神经麻痹患者中喉返神经修复术6例中, 术后呼吸困难缓解及声带外展部分恢复4例;非神经修复术10例术后呼吸困难改善;神经修复组术后拔管率为66.7%, 非神经修复组术后拔管率为100%;Fisher精确概率法比较两组术后拔管率, 差异无统计学意义(P>0.05)。结论 对于单侧声带麻痹, 喉返神经修复术及非喉返神经修复术疗效相当, 前者的远期疗效更佳。对于双侧声带麻痹, 非喉返神经修复术疗效更佳, 但喉返神经修复术不影响患者的发音功能。选择喉返神经修复术或非喉返神经修复术治疗声带麻痹, 需要医师根据自身的专业知识及技能、患者的身体状况及需求, 作出慎重的决定, 以取得可靠的疗效。     

Laryngeal problems following infant esophageal surgery

This paper focuses on vocal cord paralysis in children after operation for tracheoesophageal fistula and/or esophageal atresia. We reviewed the charts of 65 children who were operated upon for congenital esophageal atresia and/or tracheoesophageal fistula during a period from 1964 to 1974. Ten of these children manifested laryngeal symptoms. Five had laryngeal paralysis. Two were untreated. One was treated with cordectomy and stent. Two were treated successfully with the Thornell arytenoidectomy, one of these being done without a tracheotomy in place. Mention is made of a third case of bilateral vocal cord paralysis due to hydrocephalus treated successfully by the Thornell procedure. Follow-up laryngoscopy was done on 21 children without laryngeal symptoms which revealed two previously unsuspected vocal cord paralyses and one vocal cord paresis which cleared.     

The assistance of coblation in arytenoidectomy for vocal cord paralysis

Background: There are many causes for vocal cord paralysis, which can cause difficulty in breathing in serious cases. The common surgical methods for solving vocal cord paralysis include laryngeal splitting or laser surgery, but there are limitations. Plasma radiofrequency ablation is a new treatment with good achievements in clinical applications.

Objective: To investigate the effect of coblation-assisted arytenoidectomy (CSA) in the treatment of bilateral vocal cord paralysis (BVCP).

Methods: All patients had undergone preoperative electrolaryngoscopic examination of the glottidis rima; electronic laryngoscopy can assess the width of the glottis. The purpose of preoperative electronic laryngoscopic evaluation is to assess the width of the glottis, and arytenoid cartilage movement. Unilateral arytenoid cartilage and a section of the vocal cords were removed in all cases.

Results: Of the 14 patients, 13 were successfully extubated after CSA; 1 patient could not be extubated and underwent a second CSA of the contralateral arytenoid cartilage, after which extubation was achieved. All patients were continuously followed up (6 months to 2 years), and all achieved satisfactory results.

Conclusions and significance: CSA can effectively relieve post-CSA dyspnea in patients with BVCP. More patients underwent tracheal cannula extubation after tracheotomy compared with other surgeries.     

Congenital stridor with feeding difficulty as a presenting symptom of Dok7 congenital myasthenic syndrome

Objective

The congenital myasthenic syndromes (CMS) are a group of genetic disorders of neuromuscular transmission causing fatigable weakness. Symptoms may be present from birth, but diagnosis is often delayed for several years, notably in post-synaptic CMS due to mutations in the DOK7 gene. Recently, we noted a subgroup of children with CMS in whom congenital stridor and bilateral vocal cord palsy predated other symptoms. All had mutations in the DOK7 gene. The purpose of this study was to review our population of DOK7 CMS patients with congenital stridor and assess whether there were other phenotypic features which might raise suspicion of a diagnosis of CMS in the neonatal period, in the absence of limb weakness and ptosis and prompt earlier referral for neurophysiological investigation, genetic diagnosis and appropriate treatment.

Methods

A retrospective case review of 11 DOK7 CMS patients at a tertiary referral centre.

Results

Six patients were identified with DOK7 mutations and congenital stridor, four requiring intubation soon after birth. Four patients had a diagnosis of bilateral vocal cord palsy and three required tracheostomy, successfully decannulated in one after 3 years. All six patients had difficulty with feeding, with weak suck and swallow necessitating nasogastric feeding in five, two of whom required gastrostomy. Despite all six children having had neonatal symptoms, the mean age at CMS diagnosis was 5 years and 9 months.

Conclusion

CMS, particularly caused by mutations in the DOK7 gene, is a rare but treatable cause of congenital stridor in the neonate. A combination of congenital stridor, especially with an apparently idiopathic bilateral vocal cord palsy and weak suck and swallow should alert the clinician to the possibility of CMS and prompt early referral for neurophysiology and genetic investigations. Confirmation of a CMS diagnosis enables treatment to be initiated, informed management of the VCP and anticipation of myasthenic symptoms, particularly life-threatening respiratory decompensation. Treatment may allow early decannulation or possible avoidance of tracheostomy. At least 12 genes are known to cause CMS; the presence of congenital stridor may help target genetic diagnosis.     

Airway management in anaplastic thyroid carcinoma

Objectives/Hypothesis: In patients who present with advanced anaplastic thyroid cancer, airway management is difficult because of bilateral vocal cord paralysis or tracheal invasion by the tumor. Airway management can be extremely complex in these patients. Study Design: This is the author's 25 year experience with 30 patients who presented with anaplastic thyroid cancer and acute airway problems. Methods: The patients' airway issues developed soon after presentation or a few months after treatment. Ten patients presented with initial symptoms of acute airway distress. All of these patients were treated with tracheostomy or cricothyrotomy. Results: The 10 patients who presented with initial symptoms of acute airway distress died within 4 months. Eight of the remaining 20 patients developed bilateral vocal cord paralysis. Airway management for these patients depended on the extent of distant disease and the family's understanding of the advanced nature of the disease and the palliative efforts. The remaining patients had a palliative and supportive approach. Conclusions: Airway management was the most critical issue in patients who presented with anaplastic thyroid cancer and initial airway distress. Cricothyrotomy was helpful in avoiding acute airway catastrophe. It is important to distinguish between poorly differentiated and anaplastic thyroid cancer and lymphoma for appropriate airway management.     

双声带楔形切除术治疗双侧声带外展麻痹

目的：探讨治疗双侧声带外展麻痹的微创外科手术方式——显微支撑喉镜下CO2激光双声带楔形切除术的临床应用价值。方法：使用显微支撑喉镜激光手术系统,治疗4例双侧声带外展麻痹患者。结果：3例经过1次手术,1例经过2次手术,随访5-36个月,患者呼吸困难完全缓解,能耐受日常生活活动;4例均对自己的声音较为满意,能进行日常的生活交流。结论：显微支撑喉镜CO2激光双侧声带楔形切除术,不需气管切开,术后喉功能恢复快,并发症少。既能解决患者通气的要求,又能保证发声的质量,本方法治疗双侧声带外展麻痹有很好的临床推广使用价值。     

支撑喉镜下杓状软骨切除联合声带外移治疗双侧声带外展麻痹的临床研究

目的探讨支撑喉镜下单侧杓状软骨全切除联合同侧声带外移治疗双侧声带外展麻痹的手术方法和临床意义。方法支撑喉镜下对30例双侧声带外展麻痹伴呼吸困难的患者行CO2激光单侧杓状软骨全切除并用Ejnell法同侧声带外移扩宽声门,手术前、后纤维喉镜检查声门情况,嗓音分析评估发音功能,肺功能检查评估通气情况。结果 30例患者拔管率100%。随访6个月-5年,全部病例无肉芽生长和再狭窄等并发症,均保持语言交流功能。嗓音分析显示基频微扰、振幅微扰手术前、后差异无显著性意义（P均〉0.05）,但手术前、后声门噪声能量、最长声时差异有显著性意义（P均〈0.05）。肺功能显示FEV1、FEV1/FVC手术前、后差异有显著性意义（P均〈0.05）,客观反映了术后气道通气功能改善。结论支撑喉镜下单侧杓状软骨全切除联合同侧声带外移可有效治疗双侧声带外展麻痹,且拔管早,拔管率高,疗效持久,患者的发音功能得到满意的保留,是治疗该类患者的较为理想的方法。     

Obstructive sleep apnea syndrome and snoring in patients with bilateral vocal cord paralysis

The analysis of the correlation between bilateral vocal cord paralysis and the occurrence of obstructive sleep apnea syndrome and snoring is presented. The aim of the study was to establish whether the decrease of the air flow in the upper airway in patients with bilateral vocal cord paralysis involves OSAS and/or snoring occurrence and whether arytenoidectomy affects an improvement of breathing parameters measured during sleep. Fourteen patients with bilateral vocal cord paralysis underwent Poly-MESAM examination before and 3 months after arytenoidectomy. They had never complained of snoring before. The Epworth sleepiness scale was used to quantify excessive daytime somnolence. The RDI, DI, mean saturation and percentage of snoring, loud snoring and sleep without snoring were estimated and compared pre- and postoperatively. The results were compared by the Student's t-test for dependent values. No significant differences were shown between the Epworth scores before and after the treatment. The RDI, DI and mean saturation were normal before and after the operation. The percentage of loud snoring decreased and the percentage of sleep without snoring increased significantly after arytenoidectomy in both cases. The mechanism of snoring in patients with vocal cord paralysis seems to be similar to OSAS. The difference consists in the level of flow limitation. On the basis of the results there is no reason to diagnose OSAS and UARS in patients with bilateral vocal cord paralysis. On the other hand, the intensive snoring that occurs after paralysis was significantly reduced as a result of arytenoidectomy.     

Bilateral vocal cord paralysis in children

Bilateral vocal cord paralysis in children with its many causes presents a challenging problem to the pediatric otolaryngologist. Traditionally, management of bilateral vocal cord paralysis includes securing the airway with a tracheotomy and waiting for spontaneous recovery. Surgeons have tried a variety of surgical procedures in lieu of or in addition to tracheotomy, but none are perfect solutions to the problem. This article reviews the current surgical procedures for bilateral vocal cord paralysis in the pediatric population with a particular focus on the senior author's experience with the endoscopic posterior costal cartilage grafting procedure.     

Treatment of bilateral vocal cord paralysis following permanent recurrent laryngeal nerve injury

Bilateral vocal cord paralysis is a serious illness requiring emergency intervention to resolve the potentially life-threatening respiratory distress. Several surgical procedures were proposed to help improve the airway and to eliminate the tracheostoma in those patients with permanent paralysis. All the procedures have their own advantages and disadvantages. We conducted a retrospective study of 30 patients affected by bilateral vocal cord paralysis following total thyroidectomy. All the patients underwent total thyroidectomy for benign thyroid pathology. In 26 patients (86.6%), cord paralysis occurred during the perioperative stage; and in the remaining 4 cases (13.3%), it occurred within the following 6 months. We treated all these bilateral recurrent laryngeal nerve paralysis patients with arytenoidectomy alone in 5 patients and arytenoidectomy with concomitant true and false posterior cordectomy in the remaining 25 patients. Twenty-four of the 25 patients who underwent the combined procedures (96%) reported subjective respiratory improvement and were decannulated within 60 days, being able to return to their normal daily activities. This study demonstrates that arytenoidectomy associated with posterior cordectomy is a satisfactory surgical treatment of bilateral vocal cord paralysis because it leads to a considerable and stable enlargement of the breathing space.