Intubation‐Related Laryngeal Deficiency and Vocal Fold Immobility in Pediatric Premature Patients

Abstract

Objectives/Hypothesis We report a posterior laryngeal rating system and measures of voice disability in pediatric patients undergoing phonosurgery for vocal fold paralysis. Posterior glottic deficiency may account for persistent voice disability. Study Design Retrospective Study. Methods Retrospective analyses of 66 subjects with primary unilateral vocal fold paralysis were reviewed for the status of posterior glottis and voice disability (Pediatric Voice Handicap Index [pVHI]). Gestation age (GA), weight, and medical/surgical history were reviewed. The width, length, and depth of the larynx were analyzed to create a reproducible rating scale. Results Mean GA was 29 weeks, with an intubation history for all subjects, with 90% having a left vocal fold immobility. Cardiac surgery was performed in 92% of subjects. A progressive rating (type 0–3) Benjamin Defect Severity Scale (BDSS) was developed to rate the absence or presence of a posterior abnormality. BDSS‐2 and BDSS‐3 subjects were more likely to have low birth weight. Extremely preterm GA was more likely to be associated with BDSS‐1 (mild) or BDSS‐2. History of multiple and prolonged intubations were seen more frequently in BDSS‐2 or BDSS‐3. Post‐op pVHI reduced an average of 15 points for BDSS‐0 to BDSS‐2, but only 3 points for BDSS‐3. Post‐op pVHI matched normal values for preintervention dysphonic children. Conclusions The presence of a persistent breathy voice after intervention for unilateral vocal fold immobility is potentially associated with posterior glottic defects. Low birth weight with multiple/prolonged intubation is more likely to be present with higher‐grade BDs, whereas low GA is more likely to be associated with BDSS‐1 to BDSS‐2. Level of Evidence 4 Laryngoscope, 131:2550–2557, 2021

Scoping Review of Surgical Rehabilitation of Post Intubation Phonatory Insufficiency

“…Laryngeal framework surgery, Type I (medialization) thyroplasty is also indicated in cases of glottic insufficiency or paralysis, whereby an implant (generally Gore‐Tex or silastic) is inserted into the paraglottic space medializing the VF and correcting insufficiency 20 . Zur et al studied pediatric patient who underwent medialization for unilateral VF paralysis and postulated that persistent breathiness after medialization was due to PGI not addressed by thyroplasty 21 . Again, this suggests that there may be a large group of patients undergoing surgery for hypomobility or VF atrophy who have underlying PGI.…”

“…20 Zur et al studied pediatric patient who underwent medialization for unilateral VF paralysis and postulated that persistent breathiness after medialization was due to PGI not addressed by thyroplasty. 21 Again, this suggests that there may be a large group of patients undergoing surgery for hypomobility or VF atrophy who have underlying PGI. This further highlights that PIPI should be a consideration in patients with unsuccessful thyroplasty and coexisting intubation history.…”

Complications during mechanical ventilation—A pediatric intensive care perspective

“…Laryngoscopic assessment is the gold standard for assessment of dysphonia in children. Recurrent laryngeal nerve reinnervation is a treatment option for pediatric patients with persistent unilateral vocal fold immobility ( 40 ).…”

Prophylactic Oropharyngeal Surfactant for Preterm Newborns at Birth

“…Exogenous surfactant, given via an endotracheal tube (ETT), revolutionized the care of preterm newborns in the 1990s . However, laryngoscopy, intubation, and mechanical ventilation are associated with adverse outcomes . Treating preterm newborns with continuous positive airway pressure (CPAP) and reserving intubation, surfactant, and ventilation for newborns whose breathing worsens despite CPAP has been associated with better results than routinely intubating this population for surfactant administration .…”

“… 3 , 4 , 5 However, laryngoscopy, intubation, and mechanical ventilation are associated with adverse outcomes. 6 , 7 , 8 Treating preterm newborns with continuous positive airway pressure (CPAP) and reserving intubation, surfactant, and ventilation for newborns whose breathing worsens despite CPAP has been associated with better results than routinely intubating this population for surfactant administration. 9 Randomized clinical trials 10 , 11 , 12 that compared CPAP with intubation reported rates of mechanical ventilation in the days after birth of 40% to 60% among preterm newborns on CPAP.…”