Unilateral vocal fold paralysis in children has many different etiologies that can result in difficulties with breathing, swallowing, or phonation. Depending on the severity of symptoms, treatment modalities range from non-surgical interventions, to temporary surgical procedures, or more permanent surgical options. Laryngeal reinnervation has been demonstrated as an appropriate treatment option for children with permanent laryngeal nerve damage and persistent symptoms, but it still not widely performed among pediatric otolaryngologists. In this case, we present a 6 year-old female patient who developed unilateral vocal fold paralysis from a cardiac procedure as an infant, and she subsequently underwent laryngeal reinnervation with ansa cervicalis-to-recurrent laryngeal nerve (ANSA-RLN) anastomosis. The patient tolerated the procedure well with no peri-operative complications and demonstrated symptomatic improvement in voice quality and swallowing at her 3 month follow-up appointment. The goal of this case is to demonstrate the steps of the laryngeal reinnervation procedure and acknowledge its importance as a treatment option for unilateral vocal fold paralysis in pediatric patients.
Cori N Walker MD1, Christopher Blake Sullivan MD1, Sohit P Kanotra MD1
Department of 1Otolaryngology – Head and Neck Surgery
University of Iowa Hospitals and Clinics, Iowa City, IA, USA
After induction and mask ventilation, a grade I view was achieved with a pediatric Lindholm laryngoscope, the focal folds were instilled with 4% lidocaine solution, and the patient was placed in rigid suspension. For the injection laryngoplasty, 0.1 militers of Prolaryn gel (consists of carboxymethylcellulose and glycerin) was instilled into the left thyroid arytenoid muscle. Increased bulk of the left vocal fold was noted after injection and the laryngoscope was removed from the oral cavity. The patient was then successfully intubated and management of the airway was turned over to anesthesia.
The procedure was completed under general anesthesia with orotracheal intubation. Paralysis was not used to allow for stimulation of nerves for confirmation.
The patient’s left neck was prepped and draped in sterile fashion. A left neck incision was made at the level of the cricoid, and dissection was carried down to the anterior border of the sternocleidomastoid. The descending branch of the ansa cervicalis from the hypoglossal nerve was located at the intersection of the internal jugular vein, omohyoid muscle and sternocleidomastoid. A checkpoint probe was placed on the nerve, with expected stimulation of surrounding strap musculature. Careful dissection was performed for increased exposure of the ansa cervicalis nerve branch.
We then turned our attention to locating the left recurrent laryngeal nerve. The strap muscles were divided at the midline raphae and blunt dissection was completed to the level of the left thyroid lobe. The left recurrent laryngeal nerve was identified just lateral to the left thyroid lobe, coursing deep to the inferior thyroid artery. The inferior thyroid artery was divided and the recurrent laryngeal nerve was dissected in a 360 degree fashion. A vessel loop was placed around the nerve, inferior to the level of the inferior thyroid artery intersection.
Using forceps, a tunnel was created between the strap muscles for transposition of the ansa cervicalis branch to the left recurrent laryngeal nerve. The ansa cervicalis branch was dissected in a 360 degree fashion, divided, and the superior portion was passed through the tunnel. The vessel loop was then removed from the left recurrent laryngeal nerve. The nerve was further dissected and divided, and the superior portion was brought in close proximity to the end of the ansa cervicalis branch.
The sterile operating microscope was brought into the field for the neurorrhaphy portion of the procedure. Under the microscope, end-to-end anastomosis of the epineurium of the left ansa cervicalis branch to the left recurrent laryngeal nerve was performed using 9-0 nylon interrupted sutures. The wound was closed, and the patient tolerated the procedure well without any complication.
We describe the case of a 4-year-old female with a history of PDA ligation at 6 weeks of age who presented with symptoms of dysphonia and dysphagia. She was born at 28 weeks gestation and has a past medical history of necrotizing enterocolitis, requiring extensive resections with development of short gut syndrome and G-tube dependence. On physical examination, the patient had a raspy, soft voice. In office flexible laryngoscopy demonstrated left vocal fold paralysis with glottic incompetence, and a mobile, normal appearing right vocal fold. The upper aerodigestive tract endoscopy was otherwise normal.
Treatment options for unilateral VFP were discussed with her parents, including injection medialization laryngoplasty and laryngeal reinnervation, and the decision was made to initially perform an injection laryngoplasty. Laryngeal electromyography done at the time of the injection laryngoplasty revealed absence of an action potential from the paralyzed left vocal fold with normal active action potentials from the right vocal fold. In follow-up after injection laryngoplasty, the patient’s parents were satisfied with improvement in voice quality but expressed an interest to pursue a permanent treatment option. The risks, benefits and alternatives of laryngeal reinnervation were discussed with the caretakers and written consent was obtained.
Ansa cervicalis innervates the omohyoid, sternohyoid and sternothyroid muscles. It arises from a small loop between C1 and C2, and the superior root joins fibers of the hypoglossal nerve to descend in front of the carotid arteries. The inferior root of ansa cervicalis is formed by C2 and C3 and descends posterior to the carotid sheath. Either lateral to the internal jugular vein or between it and the common carotid artery, the ansa loops to connect the superior and inferior roots. The cricothyroid joint is the most consistent landmark for identification of the recurrent laryngeal nerve. When the thyroid gland is present, this joint is identified just adjacent to the tubercle of Zuckerkandl. The nerve can be located with careful dissection at the level of the joint, and the left recurrent laryngeal nerve takes a paratracheal path relative to the right, which often courses at a more obtuse angle to the tracheoesophageal groove. Another option for identification of the recurrent laryngeal nerve is a more distal approach, as the inferior segment of the nerve is most often located posterior and deep to the inferior thyroid artery, as was in this case.
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Review Pediatric Laryngeal Reinnervation with Ansa Cervicalis to Recurrent Laryngeal Nerve Anastomosis.