Vocal Fold Motion Impairment Research Articles

Effectiveness of intraoperative nerve monitoring in reducing rates of recurrent laryngeal nerve injury in aerodigestive and cardiovascular pediatric surgery

ObjectiveTo investigate the effectiveness of intraoperative nerve monitoring at decreasing vocal fold movement impairment in children undergoing at-risk procedures. BackgroundChildren undergoing aerodigestive or cardiovascular procedures are at risk for recurrent laryngeal nerve injury, leading to vocal fold movement impairment. Although intraoperative nerve monitoring has been shown to decrease recurrent laryngeal nerve injury in adults, there is paucity of data in children. MethodsThis was a retrospective, single-center cohort study of children who underwent airway, esophageal, or great vessel surgery between 2018 and 2023. Vocal fold movement impairment was evaluated with pre- and postoperative awake flexible fiberoptic laryngoscopy. Vocal fold movement impairment rates and associated characteristics were compared between those with and without intraoperative nerve monitoring. ResultsAmong 387 children undergoing 426 at-risk procedures, intraoperative nerve monitoring was used in 72.1% (n = 307) of procedures. Intraoperative nerve monitoring significantly reduced postoperative vocal fold movement impairment compared with those without (11.4% vs 20.2%, P = .019, 43.6% relative risk reduction, number needed to treat: 12). In children with a pre-existing vocal fold movement impairment (n = 79, 18.5%), intraoperative nerve monitoring provided enhanced protection (vocal fold movement impairment 7.8% with intraoperative nerve monitoring compared with 25% without, P = .046, 68.6% relative risk reduction, number needed to treat: 3). Bilateral vocal fold movement impairment was 14 times more likely without intraoperative nerve monitoring (1.8% overall, 0.3% with intraoperative nerve monitoring, 5.6% without; 95% confidence interval 1.6–123.2; P = .006). Increasing intraoperative nerve monitoring use correlated with decreasing vocal fold movement impairment rates year over year (P = .046). Multivariable logistic regression demonstrated intraoperative nerve monitoring to remain significantly associated with reduced risk of vocal fold movement impairment (odds ratio, 0.48; 95% confidence interval, 0.26–0.85; P = .013). ConclusionIntraoperative nerve monitoring in children seems effective at decreasing recurrent laryngeal nerve injury and consequently vocal fold movement impairment. Intraoperative nerve monitoring should be considered in children undergoing cervicothoracic or cardiothoracic procedures, especially in those with preoperative vocal fold movement impairment.

Esophageal Dysmotility in Multiple System Atrophy: A Retrospective Cross-Sectional Study.

Background/Objective: Multiple system atrophy (MSA) is often associated with dysphagia and esophageal dysmotility (ED). However, ED in patients with MSA is poorly understood. To assess the relationship between ED, dysphagia, and other clinical findings in such patients and investigate the details of ED in MSA using high-resolution manometry (HRM). Methods: Patients from The University of Tokyo Hospital with MSA who underwent swallowing examinations, esophagography, and HRM between 2017 and 2022 were enrolled. A retrospective chart review of patients' backgrounds, swallowing function, and esophageal motility was performed. ED was evaluated using the Chicago Classification version 4.0. Results: Seventy-four patients with MSA were identified. The median age was 64 years, 48 patients (65%) were male, and the cerebellar variant type was predominant (69%). Abnormal upper esophageal sphincter (UES) resting pressure was observed in 34 patients (46%) and intraesophageal stasis in 65 (88%). High-severity MSA was a risk factor for developing dysphagia, vocal fold movement impairment, and abnormal UES function (p < 0.05). However, no overt clinical risk factors for ED were identified. Various types of ED were detected using HRM, and ineffective esophageal motility was the most frequent disorder. Conclusions: ED is a common occurrence in patients with MSA. Although a high-severity MSA may be a risk factor for developing dysphagia and vocal fold motion impairment, ED can occur regardless of clinical severity. Since ED is rarely detected based on subjective symptoms, careful evaluation of esophageal motility by esophagography or HRM is warranted in patients with MSA.

Stimulated Vocal Fold Immobility After Vagal Nerve Stimulator Placement: A Case Series.

Vagal nerve stimulator (VNS) implantation is a vital therapy for epilepsy refractory to other treatments; however, it is associated with a very high rate of voice changes. Relatively few of these patients are evaluated for vocal fold motion impairments. In this series, we evaluate 5 such patients with a novel phenotype of forced abduction with VNS stimulation. Retrospective case series. Five patients with a VNS implant who underwent operative direct or in-office rigid laryngoscopy and had vocal fold motion impairment associated with VNS activation are included. All 5 patients had vocal fold mobility with VNS off and a fixed with activation. All patients exhibited vocal fold abduction with VNS activation. Patient 2 has since undergone laryngeal reinnervation, which helped her intermittent dysphonia but left a small glottic gap. A type 1 thyroplasty corrected this gap and improved her voice further. Patient 3 has undergone laryngeal reinnervation for which early results show improvement in perceptual and patient reported outcomes. Patients 4 and 5 have both undergone laryngeal reinnervation with improvement in voice. Previous reported cases of stimulated immobility associated with VNS use describe only adduction of the vocal fold. This series expands the previous work showing the VNS activation can also cause stimulated immobility in an abducted position, for which reinnervation and other medialization procedures offer promising treatment.

Analysis of 1782 Pediatric Hoarseness Cases: A Clinical Retrospect Study

ObjectiveThis study aims to clarify the clinical characteristics of pediatric voice disorders. MethodsThe clinical data of 1,782 pediatric patients presenting with voice disorders were retrospectively analyzed. These cases were categorized into four age-based cohorts: 0–3 years, 4–7 years, 8–11 years, and 12–15 years. Variables such as gender disparities, laryngoscopic manifestation, disease types, and acoustic parameters were thoroughly examined. ResultsA total of 1,782 children with acoustic hoarseness were included in this study, comprising 1,325 males and 457 females. When the sex ratio among the children in each group was compared, males were found to outnumber females. A notable male predominance was observed across all age groups.Laryngoscopic results revealed that the most prevalent condition was vocal cord nodules (1,363 cases, 76.48%), followed by vocal cord polyps (271 cases, 15.20%). Other diseases included laryngeal papillomas, vocal fold movement impairment, vocal cord cysts, functional dysphonia, leukoplakia of the vocal cords, and benign laryngeal tumors such as laryngeal amyloidosis and subglottic granular cell tumors. Among these, adenoid hypertrophy was presented in 382 children (21.44%). Additionally, the Reflux Finding Score (RFS) was conducted, and 799 cases (44.83%) were found to have a score above 7.The distribution of various diseases across different age groups indicated that children with vocal cord nodules (637 cases, 46.74%), vocal cord polyps (109 cases, 40.22%), and laryngeal papillomas (35, 36.84%) were predominantly found in the 4–7 years age group. Pediatric acute laryngitis (3 cases, 75%) and vocal fold movement impairment (8 cases, 36.36%) were more common in the 0–3 years age group. Functional dysphonia (4 cases, 66.67%) and vocal cord leukoplakia (4 cases, 80%) were mainly observed in the 12–15 years age group, while vocal cord cysts were predominantly seen in the 8–11 years age group (4 cases, 57.14%).A comparative analysis of acoustic parameters among 153 children showed statistically significant differences in jitter, fundamental frequency (F0), voice handicap index (VHI), reflux symptom index (RSI), and reflux finding score (RFS) across different pathologies. ConclusionThis study highlighted that vocal cord nodules, vocal cord polyps, and laryngeal papillomas were the primary causes of pediatric hoarseness, although the possibility of tumors and rare diseases cannot be disregarded. There was a noticeable gender bias towards males, and functional dysphonia was significantly more prevalent in older children.

Bilateral Vocal Fold Motion Impairment Associated With Diffuse Idiopathic Skeletal Hyperostosis.

To describe the clinical courses and interventions of symptomatic patients with bilateral vocal fold motion impairment (BVFMI) attributed to diffuse idiopathic skeletal hyperostosis (DISH). Retrospective cohort study. Single Institution Academic Health Center. Retrospective chart review of patients ≥18 years old evaluated and treated for symptomatic BVFMI secondary to DISH between February 2021 and March 2023. A literature review was conducted. A total of 4 cases were identified. All patients were male and had symptomatic BVFMI attributed to cervical spine DISH, as seen on imaging. Symptoms ranged from life-threatening dyspnea to breathy dysphonia in addition to dysphagia. Each patient was offered surgery for DISH. Two patients underwent osteophyte removal at the C5-C6 level with improved vocal fold (VF) mobility, breathing, and voice quality. Two patients elected serial observation as voice, swallow, and airway symptoms were manageable. The literature review showed a male-dominant (100%) presentation with an average of 70 years of age. Hypertension (45%) and diabetes mellitus (36%) were the most common comorbidities. Most patients were treated surgically (55%). Both surgical and conservative interventions may be considered for symptomatic relief and improvement in VF mobility on a patient-to-patient basis. Further study is warranted to investigate the etiology and treatment outcomes in these cases.

Vocal Fold Motion Impairment in Neurodegenerative Diseases.

Vocal fold motion impairment (VFMI) is the inappropriate movement of the vocal folds during respiration, leading to vocal fold adduction and/or abduction problems and causing respiratory and vocal impairments. Neurodegenerative diseases (NDDs) are a wide range of disorders characterized by progressive loss of neurons and deposition of altered proteins in the brain and peripheral organs. VFMI may be unrecognized in patients with NDDs. VFMI in NDDs is caused by the following: laryngeal muscle weakness due to muscular atrophy, caused by brainstem and motor neuron degeneration in amyotrophic lateral sclerosis; hyperactivity of laryngeal adductors in Parkinson's disease; and varying degrees of laryngeal adductor hypertonia and abductor paralysis in multiple system atrophy. Management of VFMI depends on whether there is a presence of glottic insufficiency or insufficient glottic opening with/without severe dysphagia. VFMI treatment options for glottic insufficiency range from surgical interventions, including injection laryngoplasty and medialization thyroplasty, to behavioral therapies; for insufficient glottic opening, various options are available based on the severity and underlying cause of the condition, including continuous positive airway pressure therapy, botulinum toxin injection, tracheostomy, vocal fold surgery, or a combination of interventions. In this review, we outline the mechanisms, clinical features, and management of VFMI in NDDs and provide a guide for physicians who may encounter these clinical features in their patients. NDDs are always progressive; hence, timely evaluation, proper diagnosis, and appropriate management of the patient will greatly affect their vocal, respiratory, and swallowing functions as well as their quality of life.

A Single Center Description of Adult and Pediatric Endoscopic Posterior Costal Cartilage Grafting.

Posterior glottis impairment alters breathing, voicing, and swallowing. Bilateral vocal fold movement impairment (BVFMI) occurs when the vocal cords are fixed/remain midline. Studies inadequately assessed endoscopic posterior costal cartilage grafting (enPCCG) for BVFMI across broad ages. We aim to assess decannulation and prosthesis free airway in children and adults who have undergone enPCCG. Retrospective cohort. Referral center. This study included adults and children who received enPCCG for BVFMI (2010-2018) and were followed for 35 months on average. The main outcome was successful decannulation of patients, or airway improvement in those without tracheostomy. Data on comorbidities, surgical complications, and interventions following surgery were collected. Ten children and 11 adults underwent enPCCG for BVFMI. Eighty-one percentof patients had a tracheostomy at surgery; adults were more likely to have a tracheostomy at surgery (P = 0.035), and to undergo double-staged procedure (P = 0.035) and stent (P = 0.008). Average stent duration was 29.7 days. Overall decannulation rate was 76% (90% for children; 70% for adults). Children were more likely to receive postoperative intensivecareunit care (P = 0.004). Adults had mean 4.4 post-enPCCG interventions per patient compared to children's mean 3.91 interventions. The most common interventions were steroid injection (17.6%) and balloon dilation (16%). Preliminary analysis suggests postoperative dysphonia was reported in 66.7% of patients; postoperative dysphagia was rare. EnPCCG was more successful at achieving decannulation in children. Adults required additional interventions. A double-staged operation with prolonged stenting is recommended for adult patients. A majority of patients were decannulated at last follow-up.

Factors Associated with Iatrogenic Laryngeal Injury in Recurrent Respiratory Papillomatosis.

To describe iatrogenic laryngeal injury and identify its risk factors in recurrent respiratory papillomatosis (RRP) patients receiving surgical care. Case-control. Tertiary care academic hospital in a metropolitan area. Charts of patients with RRP seen at our institution from January 2002 to December 2022 were reviewed. Patients were separated into 2 cohorts based upon whether they experienced any form of iatrogenic laryngeal injury-including anterior commissure synechiae, vocal cord scar, reduced vocal fold pliability, vocal fold motion impairment, and glottic and/or subglottic stenosis. Adjusted logistic regressions were performed to identify factors associated with iatrogenic laryngeal injury. Of 199 RRP patients, 133 (66.8%) had identifiable iatrogenic laryngeal injury. The most common injuries were anterior commissure synechiae (n = 67; 50.4%) and reduced vocal fold pliability (n = 54; 40.6%). On a multivariate logistic regression, patients with diabetes mellitus (adjusted oddsratio [aOR] [95% confidence interval [CI]]: 2.99 [1.02, 8.79]; P = .04) and who received at least 10 surgeries lifetime (aOR [95% CI]: 14.47 [1.70, 123.19]; P = .01) were at increased risk for iatrogenic laryngeal injury, whereas receiving less than 5 surgeries (aOR [95% CI]: 0.21 [0.09, 0.51]; P < .001) was found to be protective. When treating the lifetime number of surgeries as a continuous variable, a greater number of surgeries was a significant risk factor for iatrogenic laryngeal injury (aOR [95% CI]: 1.32 [1.14, 1.53]; P < .001). These results suggest the importance of strict glucose control for diabetic patients receiving RRP surgical care, and emphasize the clinical need to identify medical therapies to decrease RRP surgical frequency for patients.

Current opinion in otolaryngology and head and neck surgery: the role of the otolaryngologist in the management of pediatric dysphagia.

Dysphagia affects at least 1% of the pediatric population. This prevalence further increases in patients who are born prematurely or who have underlying neuromuscular or cardiopulmonary disorders. A multidisciplinary team approach, including an Otolaryngologist, can help promote an expedited diagnosis and therapeutic regimen, ensuring that the patient receives adequate nutrition needed for growth and development. The development and growth of multidisciplinary aerodigestive clinics have improved outcomes in pediatric patients with dysphagia. If a structural concern is noted on examination, there remain a multitude of medical and surgical options to help improve patient outcomes and swallow. These treatment options are usually multimodality and specific interventions may be employed to target a specific and notable abnormality. Pediatric dysphagia is a complex concern. For the otolaryngologist, etiologies with surgical targets may include ankyloglossia, tonsillar hypertrophy, laryngomalacia, laryngo-esophageal cleft, vocal fold movement impairment, and cricopharyngeal achalasia. The development and formalization of a multidisciplinary approach has streamlined and broadened treatment options for these patients. An otolaryngologist is integral as part of the treatment team of these patients.

Diagnostic Accuracy of Laryngeal Ultrasound for Evaluating Vocal Fold Movement Impairment in Children

PurposeVocal fold movement impairment (VFMI) secondary to recurrent laryngeal nerve (RLN) injury is a common source of morbidity after pediatric cervical, thoracic, and cardiac procedures. Flexible laryngoscopy (FL) is the gold standard to diagnose VFMI yet can be challenging to perform and/or risks possible clinical decompensation in some children and is an aerosolizing procedure. Laryngeal ultrasound (LUS) is a potential non-invasive alternative, but limited data exists in the pediatric surgical population regarding its efficacy. We aimed to investigate the diagnostic accuracy of LUS compared to FL in evaluating VFMI. MethodsA prospective, single-center, single-blinded (rater) cohort study was undertaken on perioperative pediatric patients at risk for RLN injury. Patients underwent FL and LUS. Cohen's kappa was used to determine chance-corrected agreement. ResultsBetween 2021 and 2023, 85 paired evaluations were performed with patients having a median (IQR) age of 10 (4, 42) months and weight of 7.5 (5.4, 13.4) kilograms. The prevalence of VFMI was 27.1%. Absolute agreement between evaluations was 98.8% (kappa 0.97, 95% CI: 0.91–1.00, P < 0.001). The sensitivity and specificity of LUS in detecting VFMI was 95.7% and 100%, yielding a positive predictive value (PPV) of 100% and negative predictive value (NPV) of 98.4% (95% CI: 90–100%). Diagnostic accuracy was 98.8% (95% CI: 93–100%). ConclusionLUS is a highly accurate modality in evaluating VFMI in children. While FL remains the gold standard for diagnosis, LUS offers a low-risk screening modality for children at risk for VFMI such that only those with an abnormal LUS or presence of clinical symptoms discordant with LUS findings should undergo FL. Type of StudyProspective, single-center, single blinded (rater), cohort study. Level of EvidenceLevel II.

Swallowing Characteristics in Patients with Multiple System Atrophy Analyzed Using FEES Examination

Patients with multiple system atrophy (MSA) frequently experience dysphagia but only few studies analyzed its characteristics. The aim of this study was to describe the swallowing characteristics in these patients using fiberoptic endoscopic evaluation of swallowing (FEES). In addition, the swallowing abilities in patients with predominantly cerebellar MSA (MSA-C) and predominantly parkinsonian MSA (MSA-P) were compared. Twenty-five patients with MSA (16 MSA-P and 9 MSA-C) were enrolled. Clinical data including age, sex, functional oral intake scale (FOIS) score, body mass index (BMI) and the results of the global disability-unified MSA rating scale (GD-UMSARS) were collected. Three different textures of food (liquid, semisolid, solid) were provided during FEES examination. The characteristics of dysphagia (safety, efficiency, phenotype) and laryngeal movement alterations were analyzed. Delayed pharyngeal phase (92%) and posterior oral incontinence (52%) were the phenotypes more frequently seen. Penetration was more frequent with Liquid (68%), while aspiration occurred only with Liquid (20%). Residues of ingested food were demonstrated both in the pyriform sinus and in the vallecula with all the consistencies. Vocal fold motion impairment was the laryngeal movement alteration most frequently encountered (56%). No significant differences between patients with MSA-P and MSA-C in the dysphagia characteristics and laryngeal movement alterations were found. Patients with MSA frequently experience swallowing impairment and altered laryngeal mobility. Dysphagia characteristics and laryngeal movements alterations seems to be similar in MSA-C and MSA-P.

Extended partial laryngectomy with functional preservation using the rotational crico-thyrotracheopexy.

Glottic tumors with infiltration of the anterior/posterior commissure, and lesions with subglottic, cricoid, or cricoarytenoid joint infiltration have been highly controversial in the past, from the perspective of oncological safety. Although conservation laryngeal resection options exist, most are limited by the extent of resection proscribed by the technique and the postoperative functional results. Oncologically speaking, extended vertical hemilaryngectomy is often the optimal solution. However, limited reconstruction methods often compel total laryngectomy. Eight patients with vocal fold malignancy, which infiltrated the anterior and sometimes the posterior commissure and with subglottic extension and resultant uni/bilateral vocal fold motion impairment, were treated by single stage extended vertical partial laryngectomy with rotational crico-thyrotracheopexy as a functional reconstruction of the laryngeal framework. Patients were evaluated with objective and subjective function tests. Histologic examination demonstrated tumor-free margins in every case. Definitive decannulation was successful in all cases within 2 weeks. All patients had a stable and adequate airway during follow-up and reported socially acceptable voice. Oral feeding was possible in seven patients. Rotational crico-thyrotracheopexy, as a single stage reconstruction technique, is based on well-vascularized, readily available, appropriately shaped local tissues, without significant donor site morbidity or need for long-term stenting to reconstruct large laryngeal defects after extended vertical hemilaryngectomy for advanced unilateral glottic tumors and is applicable even with supra/subglottic invasion or infiltration of the contralateral vocal fold. An adequate airway can be achieved with socially acceptable voice and safe swallowing without compromising oncologic reliability. 4 (retrospective case series review).

Morbidity and mortality among neonates with esophageal atresia and/or tracheoesophageal fistula in the United States.

Although rare, esophageal atresia (EA) and/or tracheoesophageal fistula (TEF) can lead to severe morbidity and mortality. A known complication of EA and/or TEF repair is vocal fold motion impairment (VFMI). To characterize the prevalence of VFMI among repaired EA and/or TEF at a national level and to identify factors associated with in-patient mortality and common clinical endpoints in this population (tracheostomy and gastrostomy tube dependence). This is a retrospective cohort study of inpatient neonate admissions with EA and/or TEF in the 2016 Kids' Inpatient Database (KID). Patients with a history of EA and/or TEF were identified with ICD-10 codes. VFMI prevalence was assessed by observed frequencies and percentages. Clinical endpoints included gastrostomy (G-)tube placement, tracheostomy status, and inpatient mortality. Potential predictors of these three primary outcomes included cardiac anomalies, airway disorders, chromosomal anomalies, surgery within 24h of admission, prematurity, and low birthweight (LBW). Chi-squared analysis was performed between each parameter and the primary outcomes. Significant associations (p-value<0.05) were further assessed with multivariate logistic regression. Of 1062 neonates with history of EA and/or TEF, 24 (2.3%) had VFMI. Among this population, 27 patients underwent tracheostomies and 63 required G-tubes. There was a significantly higher likelihood of tracheostomy in patients with VFMI compared to patients without (16.7% versus 2.2%; p<0.01). After multivariate analysis, birthweight less than 1.5kg (BW<1.5kg; OR=2.5, 95% CI: 1.03-6.10), extreme prematurity (OR=7.5, 95% CI: 2.00-28.07), cardiac anomalies (OR=1.8, 95% CI: 1.01-3.04) and chromosomal anomalies (OR=4.2, 95% CI: 2.39-7.44) were significantly associated with in-hospital mortality. Bronchopulmonary dysplasia (BPD; OR=4.7, 95% CI: 1.73-12.78) and BW<1.5kg (OR=2.4, 95% CI: 1.05-5.49) were significant predictors for G-tube status. For tracheostomy, BPD (OR=15.8, 95% CI: 4.70-52.83) and subglottic stenosis (SS, OR=11.2, 95% CI: 1.85-68.02) remained significant predictors after multivariate regression. The national prevalence of VFMI among neonates following EA and/or TEF repair was 2.3% and was associated with an increased likelihood of tracheostomy in the KID 2016. Significant predictors of in-hospital mortality were cardiac anomalies, chromosomal anomalies, extreme prematurity, and BW<1.5kg. BPD and SS were significant predictors of tracheostomy, and BPD and BW<1.5kg were significant predictors for G-tube requirements.

Ultrasound Screening After Cardiac Surgery Shows Vocal Fold Impairment and Predicts Aspiration.

Vocal fold motion impairment (VFMI) is a known consequence after high-risk cardiac surgery. We implemented a universal laryngeal ultrasound (LUS) screening protocol for VFMI after the Norwood and aortic arch surgery. We hypothesized that LUS would accurately identify VFMI and predict postoperative aspiration. We implemented a screening algorithm with LUS for patients undergoing high-risk cardiac surgery at a tertiary care pediatric hospital. Positively screened patients underwent flexible nasolaryngoscopy (FNL). Patients with an abnormal FNL underwent a video-fluoroscopic swallow study (VFSS). Patient demographics, length of stay, and swallowing outcomes were assessed. Two-tailed chi square and Wilcoxon rank sum tests were used to assess for differences. Sixty-seven patients underwent either Norwood or arch reconstruction over a 16-month period and underwent universal LUS. The average birth weight was 3.24 kg (SD 0.57). Of the 67 patients, VFMI was identified by LUS and 100% confirmed on FNL in 58.21% (n = 39/67) of patients. Aspiration and penetration on VFSS were higher in the group with VFMI as compared with those without VFMI (53.8% vs. 21.4%, p = 0.008). There was no difference in length of stay between patients who did not have a diagnosis of VFMI and those found to have VFMI (41.0 days vs 45.3 days p = 0.73). Universal LUS screening for patients following high-risk cardiac surgery may lead to earlier identification of postoperative VFMI and aspiration. Recognition of VFMI through this universal screening program could lead to earlier interventions and possibly improved swallowing outcomes. 3 Laryngoscope, 134:1939-1944, 2024.

Characteristics of post-stroke dysphagia: A retrospective study based on FEES.

This study aims to examine the characteristics of dysphagia in stroke patients with different lesion sites and explore the factors that impact the duration of nasogastric tube after post-stroke dysphagia (PSD). Patients with PSD were screened for analysis. Stroke types and lesion sites were confirmed using MRI or CT scans. Included patients were categorized into two groups: supratentorial stroke group (including lobar and deep intracerebral stroke subgroups) and infratentorial stroke group (including brainstem and cerebellar stroke subgroups). Fiberoptic endoscopic evaluation of swallowing (FEES), Penetration-aspiration scale (PAS), Yale pharyngeal residue (PR) severity rating scale, Functional oral intake scale (FOIS), Murray secretion severity rating scale (MSS), laryngopharyngeal sensation, and vocal fold mobility were investigated to assess the swallowing function. A total of 94 patients were included in the final analysis. Significant differences were found in PR scores (p<.001), PAS scores (p<.05), MSS scores (p<.05), and vocal fold mobility (p<.001) between infratentorial and supratentorial stroke groups. Moreover, lobar stroke showed significantly higher PR scores compared to the deep intracerebral stroke group (p<.05). Kaplan-Meier survival analysis indicated significant differences in the duration of nasogastric tube placement among the following groups: infratentorial versus supratentorial stroke, PAS ≤ 5versus PAS>5, PR ≥ 3versus PR<3, and normal vocal fold mobility versus vocal fold motion impairment group (p<.05). The infratentorial stroke may lead to worse swallowing function as compared to a supratentorial stroke. Additionally, patients with infratentorial stroke, PAS>5, PR ≥ 3, or vocal fold motion impairment may contribute to a longer duration of nasogastric tube placement.

Screening for Vocal Fold Movement Impairment in Children Undergoing Esophageal and Airway Surgery.

Children undergoing cervical and/or thoracic operations are at risk for recurrent laryngeal nerve injury, resulting in vocal fold movement impairment (VFMI). Screening for VFMI is often reserved for symptomatic patients. Identify the prevalence of VFMI in screened preoperative patients prior to an at-risk operation to evaluate the value of screening all patients at-risk for VFMI, regardless of symptoms. A single center, retrospective review of all patients undergoing a preoperative flexible nasolaryngoscopy between 2017 and 2021, examining the presence of VFMI and associated symptoms. We evaluated 297 patients with a median (IQR) age of 18 (7.8, 56.3) months and a weight of 11.3 (7.8, 17.7) kilograms. Most had a history of esophageal atresia (EA, 60%), and a prior at-risk cervical or thoracic operation (73%). Overall, 72 (24%) patients presented with VFMI (51% left, 26% right, and 22% bilateral). Of patients with VFMI, 47% did not exhibit the classic symptoms (stridor, dysphonia, and aspiration) of VFMI. Dysphonia was the most prevalent classic VFMI symptom, yet only present in 18 (25%) patients. Patients presenting with a history of at-risk surgery (OR 2.3, 95%CI 1.1, 4.8, p= 0.03), presence of a tracheostomy (OR 3.1, 95%CI 1.0, 10.0, p= 0.04), or presence of a surgical feeding tube (OR 3.1, 95%CI 1.6, 6.2, p= 0.001) were more likely to present with VFMI. Routine screening for VFMI should be considered in all at-risk patients, regardless of symptoms or prior operations, particularly in those with a history of an at-risk surgery, presence of tracheostomy, or a surgical feeding tube. 3 Laryngoscope, 133:3564-3570, 2023.

Pediatric Dysphonia: When to Refer.

The reported prevalence of voice disorders in the pediatric population varies widely between studies, ranging from 3.9% to 23%. Despite this, not all children with dysphonia are referred to a voice specialist for further evaluation. The objective of this study is to examine the relationship between dysphonia history, voice assessment, and laryngeal findings to help guide referrals of dysphonic children. A retrospective review was conducted of pediatric patients at a tertiary voice clinic between January 2014 and December 2017. Data including dates of presentation, demographics, co-morbidities, presenting symptoms, laryngeal exam findings, Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) scores, and Pediatric Voice Handicap Index (pVHI) scores were collected and analyzed. Of 475 patients initially identified, 459 met inclusion criteria and were reviewed. In all, 272 (59.3%) were male and 187 (40.7%) were female. Mean age at first presentation was 8.6 years old (range: 2-18). Males were more likely to present at a younger age than females. CAPE-V data were available for 439 patients, and pVHI data were available for 109 patients. The mean CAPE-V Overall Severity score was 38.2. The mean total pVHI score was 25.4. Males had higher CAPE-V Overall Severity (40.0 vs. 35.4), Roughness (32.2 vs. 27.6), and Strain scores (37.2 vs. 32.4) than females. Patient pVHI scores did not differ by gender. In all, 283 patients self-reported a length of symptoms prior to evaluation. Children with a longer duration of symptoms prior to evaluation had higher CAPE-V Overall Severity scores. Diagnoses of vocal fold movement impairment and benign vocal fold lesions that were not nodules were associated with higher average CAPE-V Overall Severity scores. Overall, 310 patients (67.5%) were recommended intervention for their dysphonia. These patients had higher CAPE-V Overall Severity scores than those who were solely recommended observation (42.8 vs. 28.0). Males were more likely than females to present with dysphonia and presented with more severe perceptual dysphonia scores on average. The length of symptoms and certain diagnoses correlated with higher CAPE-V Scores. Referrals to a pediatric voice clinic should be considered in patients with a dysphonia history lasting greater than 3 months and in patients with more severe symptoms.

Life-threatening event after injection laryngoplasty in a patient with chemotherapy-induced vocal-fold motion impairment: A case report

Background: Although chemotherapy induced vocal fold motion impairment was first reported in 1971, there are few reports. Herein, we describe a case in which life threatening side effects occurred after injection laryngoplasty for the treatment of chemotherapy induced vocal fold motion impairment accompanied by dysphonia and aspiration in a patient with lymphoma.

A systematic review and meta-analysis on the outcomes of type I thyroplasty in the irradiated neck

BackgroundType I thyroplasty has been well-documented as a safe and effective treatment modality for vocal fold motion impairment, as well as other select cases of persistent glottic insufficiency. However, history of prior radiation to the neck has traditionally been viewed as a relative, if not formal contra-indication to this procedure. The objective of this systematic review was to analyze all available data in the literature on type I thyroplasty in previously irradiated patients and perform a meta-analysis assessing whether complications and revision rates are significantly different between radiated and non-irradiated patients. Secondary outcomes were to compare voice outcomes between these cohorts. MethodsSeveral databases were screened for relevant citations using the PICO process. The quality of studies and risk of bias were evaluated using the MINORS scoring system. Main endpoints for analysis in this study were complication rate and revision rate. Secondary endpoint was reported voice outcome. ResultsThree articles were included in the analysis. Zero major complications were reported, including no instances of implant extrusion or explantation. There was an 11.8 % rate of minor complications. There were similar rates of revision between radiation and control groups. There was no significant difference in voice outcomes between groups. The average MINORS score of the studies suggested a high risk of bias. ConclusionsBased on limited quality evidence, this review suggests that type I thyroplasty is safe and feasible in carefully selected irradiated patients, with comparable complication and success rates as their non-irradiated cohorts. Further large-scale studies are warranted.

Improving Timeliness of Vocal Fold Mechanical Injury Screening Following Norwood or Arch Reconstruction: A Quality Improvement Initiative at a Single Center.

Vocal fold (VF) immobility is a common complication after pediatric cardiothoracic surgeries involving the aortic arch and conotruncal region. Nasolaryngoscopy is considered the standard for diagnosis but is invasive and requires expertise and special resources. VF ultrasound (VF US) is an efficient, non-invasive alternative for VF evaluation in the post-cardiac surgical setting. Our aim was to improve screening rates for vocal fold motion impairment (VFMI) by implementing VF US in a group of pre-identified high-risk patients after index cardiac surgeries using Quality Improvement (QI) methodology. The QI project included formation of a widely representative stakeholder team, collaborative development of a screening protocol for the cohort of patients in our tertiary center. Baseline data were derived by retrospective review of screening and incidence of VFMI in a similar post-surgical cohort in 2years prior to this intervention. We implemented an US screening algorithm with multidisciplinary care coordination. We evaluated feeding practices and length of stay (LOS) related to our screening interventions and documented follow up practices. Screening for VFMI by ultrasound increased from 59 to 92% after implementation of the VF screening protocol. Additionally, time between extubation and VF US decreased from 7.7 to 2.3days. The positive predictive value of VF US was 96%. Patients with VFMI had a longer LOS and greater dependence on tube feeds at discharge after index surgery. We successfully implemented an ultrasound-based screening protocol for VFMI and demonstrated improved screening, timeliness and high positive predictive value of ultrasound.