The consultants agree that surgery is a common cause of unilateral vocal cord paralysis in neonates.

In the
absence of a history of surgery, they would evaluate a neonate for cardiovascular or central nervous system
anomalies. None believes a relationship between laryngomalacia and vocal cord paralysis exists. But there is
disagreement regarding the additional steps required to evaluate this child. The recommendations include
endoscopy under general anesthesia with assessment of cricoarytenoid mobility, evaluation for other congenital
anomalies, and observation of laryngeal dynamics (Dr. Benjamin), neurologic examination (Dr. Bailey), and no
further testing (Dr. Gray). Laryngeal EMG in an infant is not an established technique and none of the
consultants routinely performs this test. However, EMGs are part of the research protocol for one physician (Dr.
Gray). The consensus is that aspiration is unlikely to be a problem in this case. However, if aspiration does
occur, all would recommend conservative treatment. Feedings should be thickened and anti-reflux precautions
taken. None was convinced that severe aspiration would be a problem. However, given the need for more
aggressive treatment, the considerations would include collagen or Teflon injections or a tracheotomy (Dr.
Gray) or a Nissen fundoplication, nasogastric tube feedings, or a gastrostomy (Dr. Bailey). Only one consultant
would defer further treatment (Dr. Benjamin). The prognosis is generally good. Two consultants (Drs. Benjamin
and Bailey) would follow a child with vocal cord paralysis by periodically repeating a laryngoscopic
examination. A reinnervation procedure would be considered by one consultant at the age of 3 if the voice
remains weak (Dr. Gray).

Abstract

Neonatal vocal cord paralysis (VCP) remains an important cause of acute and chronic respiratory compromise
in infants. Despite a normal cry, infants who have bilateral VCP may present with marked respiratory distress,
and emergency tracheostomy is a lifesaving procedure in the most severe cases. Unilateral VCP usually causes
more pronounced abnormalities of the infant's voice, but respiratory symptoms are typically mild. VCP most
commonly results from iatrogenic causes due to injury to the left recurrent laryngeal nerve during cardiac
surgery. VCP also can result from congenital or neurologic disorders. Vocal cord dysfunction usually improves
over time but may take years to resolve. Infants who have VCP are at risk for aspiration, prolonged duration of
mechanical ventilation, reactive airway disease, and persistent feeding problems. Serial examination of vocal
cord function at regular intervals using flexible fiberoptic endoscopy or direct laryngoscopy is essential to
monitor airway patency and document improvement or resolution of paralysis over time. Affected infants also
must be followed closely to determine the need for future medical or surgical intervention.