Vocal Cord Paralysis and Dysphagia after Aortic Arch Reconstruction and Norwood Procedure

Abstract

Objectives Determine the incidence of vocal cord paralysis and dysphagia after aortic arch reconstruction including Norwood procedure. Setting Tertiary Children’s Hospital Study Design Retrospective cohort. Methods Database/chart review of neonates requiring Norwood or arch surgery between January 2005 through December 2012. Demographics, postoperative vocal cord function, dysphagia, need for gastrostomy tube and/or tracheotomy, and long-term follow-up were reviewed. Results One hundred fifty-one consecutive subjects(96 Norwood, 55 aortic arch) were reviewed. Median age at repair was 9 days(IQR 7–13) for Norwood, 24 days(IQR 12–49) for arch reconstruction(p<0.001). Documentation of VC motion abnormality was found in 60/104(57.6%) subjects, and unavailable in 47:16 without documentation and 31 who expired prior to extubation. There were no significant differences in proportions of documented VC motion(p=0.337), dysphagia(p=0.987), and VC paralysis(p=0.706) between the arch and Norwood groups. Dysphagia was found in 73.5% of Norwood and 69.2% of arch subjects who had documented VC paralysis. Even without UVCP, dysphagia was present (56% Norwood,61% arch). Overall, 120/151(79.5%) required feeding evaluation and modified feeding regimen. Gastrostomy was required in 31% of Norwood and 23.6% of arch reconstruction overall. To date, mortality in this series is 55/151(36.4%) patients. Of those with VC paralysis, only 23(22%) had any otolaryngology follow-up after discharge from surgery. Over 75% with VC paralysis with follow-up after hospital discharge had persistent VC paralysis 11.5 months after diagnosis. Conclusion There is high incidence of UVCP and dysphagia after Norwood and arch reconstruction. Dysphagia was highly prevalent in both groups even without UVCP. Preoperative discussion on vocal cord function and dysphagia should be considered.

Risk of Dysphagia and Speech and Language Delay in PHACE Syndrome

“…Because of the retrospective nature of the study, it is impossible to determine whether cardiac surgery or stroke led to dysphagia in some of these patients, unrelated to their PHACE syndrome diagnosis. The cardiac literature supports an incidence of dysphagia in approximately 18% to 57% of children after cardiac surgery, depending on the specific procedures that were performed . This is often attributed to prolonged ventilation or damage to the recurrent laryngeal nerve during surgical repairs, but the fact that posterior fossa abnormalities occurred in 44% of our patients with dysphagia (4/9) may support the theory that abnormal neurodevelopment is contributory in patients with PHACE syndrome as well.…”

Identification of Risk Factors for Poor Feeding in Infants with Congenital Heart Disease and a Novel Approach to Improve Oral Feeding

“…We also evaluated for the presence of vocal cord palsy postoperatively, as this is a known complication of cardiac surgery due to mechanisms including injury to the recurrent laryngeal nerve and trauma secondary to intubation, and this in turn is associated with feeding difficulties, poor growth, and need for GT placement (Einarson & Arthur, 2003; Hill et al, 2014; Pham et al, 2014; Sachdeva et al, 2007). The reported incidence of vocal cord palsy in children undergoing cardiac surgery varies from 1.7% to 8% and is associated with lower gestational age, lower birth weight, and lower surgical weight (Carpes et al, 2011; Dewan, Cephus, Owczarzak, & Ocampo, 2012; Strychowsky, Rukholm, Gupta, & Reid, 2014).…”

“…Several previous studies have noted that patients with diagnosis of hypoplastic left heart syndrome (Davis et al, 2008; Golbus et al, 2011; Kelleher, Laussen, Teixeira-Pinto, & Duggan, 2006) and postoperative vocal cord paralysis (Jadcherla et al, 2009; Pham, Connelly, Wei, Sykes, & O’Brien, 2014) are more likely to require nasogastric or gastrostomy feeds at discharge. One study of 465 infants with single ventricle heart defects found that longer periods of intubation are associated with tube feeding requirement at discharge (Hill et al, 2014), though no other studies have been done to corroborate this finding.…”

Aspiration in children with unilateral vocal fold paralysis

“…Vocal fold paralysis can be congenital or acquired; etiologies include iatrogenic, idiopathic, neurologic, and traumatic causes . Unilateral vocal fold paralysis is considered the most common neurologic disorder of the larynx and is frequently caused by intubation or neonatal cardiothoracic surgery . The diagnosis of vocal fold paralysis can be made via flexible fiberoptic endoscopy in the office or at the bedside, or by direct laryngoscopy in the operating room …”