Controversies: Neonatal vocal cord paralysis

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).