The Voice Clinic at CHOP: A Case of Unilateral Vocal Fold Immobility

Case

A 5-year-old ex 28-week premature male was referred to the Voice Clinic at Children’s Hospital of Philadelphia (CHOP) with a breathy voice. He has a history of a patent ductus arteriosus (PDA) ligation at birth and has been having issues with a weak cry since the heart procedure. He is otherwise developing well and has had several episodes of aspiration pneumonia. He is in school, but is very shy and has a difficult time being heard in loud environments.

The multidisciplinary Voice Clinic diagnosed him with a left vocal fold immobility. A clinical evaluation by our speech pathologist suggested a silent aspiration, and a modified barium swallow (MBS) study confirmed aspiration with thin liquids with improvement with nectar thick textures. Due to the pneumonias, we recommended he restrict his diet appropriately.

We performed an acoustic evaluation, and computer analysis of his voice confirmed significant voice aberration. He was deemed to be an inappropriate candidate for voice therapy due to the significant breathiness and his level of maturity. A parental proxy quality-of-life survey (pediatric Voice Handicap Index [pVHI]) revealed that the parent felt the child has a significant voice disability impacting his emotional, physical, and functional status.

Due to the silent aspiration and significant dysphonia, two options were discussed: One option was an injection laryngoplasty — a filler material injected into the left vocal fold to plump it up and help reduce the gap between the two vocal folds. This is a temporary option that is also diagnostically important to see if plumping helps the swallowing and voice. A laryngeal electromyography can be performed under the same anesthetic, and can provide some basic prognostic information about the possible recovery of vocal fold function.

The other more long-term surgical option is to perform a left recurrent laryngeal nerve reinnervation. This procedure intends to re-establish a nerve signal in the vocal fold that lost its nerve signal due to injury to the recurrent laryngeal nerve (RLN) in the chest during the cardiac procedure. RLN is a branch of the vagus nerve that exits the skull through the jugular foramen and then descends into the thorax. It re-emerges in the neck in the tracheo-esophageal groove, and for that reason it is called the “recurrent” laryngeal nerve. It is susceptible to injury during cardiothoracic, thyroid, and other neck surgeries.

The family chose the reinnervation. A branch of the ansa cervicalis nerve (descending branch of the hypoglossal nerve) is used as a donor nerve to reinnervate the damaged RLN. This nerve typically provides motor supply to the infrahyoid muscles in the neck. Within 4 months post procedure, an MBS revealed resolution of the aspiration. He was able to resume a normal nonrestricted diet. His voice strength continued to improve over the next year, and family members said they had to ask him to “be quiet” while eating at a restaurant. He has a nearly normal voice quality and excellent volume and has an intelligible speech. He needs no further treatment. The typical voice recovery following reinnervation is 3 to 20 months, with a gradual improvement in the volume and clarity of the voice.

Discussion

CHOP’s Voice Program, created in 2005, features a multidisciplinary team. We care for patients with a multitude of voice issues, including vocal cord nodules, cyst, polyp, scar, paralysis, reflux, papillomatosis, and more. An evaluation at the Voice Clinic is by professional referral and is typically for children older than 3 years of age. Our goal is to create a nurturing environment for children and their families prior to, during, and after each visit. Younger children can be seen in Otolaryngology for a basic laryngoscopic evaluation.

It is important to refer children with a voice issue that persists over a few weeks. While most voice issues in children are benign, it is incumbent on the otolaryngologist and primary care provider to rule out disease processes such as recurrent respiratory papillomatosis (caused by the human papilloma virus), vocal fold paralysis, and other medical issues that may manifest with hoarseness (such as reflux, allergies, chronic cough/asthma, functional voice disorders, etc.).

During the clinic visit, a great deal of time is spent exploring past medical and perinatal history, surgical history, and, critically, dietary habits since a large percentage of children seen in our practice have inflammation in the laryngeal region (often caused by reflux).

References and suggested readings

Zur KB, Carroll LM. Recurrent laryngeal nerve reinnervation for management of aspiration in a subset of children. Int J Pediatr Otorhinolaryngol. 2018;104:104-107.

Zur KB, Carroll LM. Recurrent laryngeal nerve reinnervation in children: acoustic and endoscopic characteristics pre-intervention and post-intervention. A comparison of treatment options. Laryngoscope. 2015;125 Suppl 11:S1-15.

Zur KB, Cotton S, Kelchner L, Baker S, Weinrich B, Lee L. Pediatric Voice Handicap Index (pVHI): a new tool for evaluating pediatric dysphonia. Int J Pediatr Otorhinolaryngol. 2007;71(1):77-82.

Daya H, Hosni A, Bejar-Solar I, Evans JN, Bailey CM. Pediatric vocal fold paralysis: a long-term retrospective study. Arch Otolaryngol Head Neck Surg. 2000;126(1):21-25.