Current trends in practices in the treatment of pediatric unilateral vocal fold immobility: A survey on injections, thyroplasty and nerve reinnervation

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Abstract

Introduction

The objective of this study was to poll pediatric otolaryngologists with a special interest in pediatric laryngology on their experience with injection medialization laryngoplasty (IML), thyroplasty, and reinnervation procedures in order to reflect on changing clinical practices.

Method

A 10-items questionnaire was designed to inquire about current management practices in the treatment of symptomatic UVFI. The 59 members of an ASPO pediatric laryngology working group received the anonymous online survey. A 47% (28/59) response rate was obtained over a 2 weeks period.

Results

Carboxymethylcellulose gel (Prolaryn) is the most popular injectable material used in the setting of IMLs (preferred by 46%; 13 respondents). Most clinicians perform IMLs in the operating room. However, 14% (4/28) of respondents currently perform office-based injections on older patients. When faced with the case of a young child with longstanding iatrogenic VFP, most respondents (41%; 11/27) would perform an IML alone as a first step for management. 37% (10/27) of respondents would inject and perform a laryngeal EMG while 22% (6/27) would offer reinnervation and concomitant IML. When faced with the case of a teenager with long-standing VFP, the polled physicians' opinions were divided: 37% (10/27) favored reinnervation and concomitant IML, while 26% (7/27) would proceed to an IML only. The remaining 37% (10/27) would first assess for vocal atrophy through LEMG or visual inspection.

Conclusions

Two significant shifts in practice seem to have occurred. First, ansa-RLN reinnervation procedures are now being considered as a first line treatment for a subset of patients in whom only IML was considered in the past. In fact, more than 20% of respondents did consider this route of management. Second, there is an increased use of in-office augmentations for older pediatric patients.

Introduction

The management of unilateral vocal fold paralysis (UVFP) in the pediatric population can be challenging. Multiple treatment options are currently available, with the 3 most common medialization procedures being injection medialization laryngoplasty (IML), thyroplasty and ansa to recurrent laryngeal nerve (RLN) reinnervation procedures [1]. The different techniques and indications have evolved over the past decade.

In regards to injection medialization laryngoplasty (IML), multiple injection products have made their way onto clinical practice within the recent years. Pediatric otolaryngologist can now choose between over 6 types of frequently used products [2,3]. Our survey aimed to look into the current choices and to establish if one injectable was most commonly used. Furthermore, there has recently been an increase in office-based procedures in the adult laryngology world [4]. In fact, given that more and more pediatric otolaryngologists are double-certified in adult laryngology and in pediatric otolaryngology, our survey aimed to identify whether practice patterns were changing according to the marriage of these two skill sets and training and whether office-based diagnostic and therapeutic procedures in children were becoming more standard.

Thyroplasty procedures are not generally considered as first-line treatment in the very young patients anymore, although previously described for aspiration cases in this subset of patients [5]. In the well-chosen, appropriate adolescent, thyroplasty may be possible in the awake but sedated patient. Reinnervation procedures are also an option, with or without simultaneous IML. This technique has shown the positive long term outcomes and we wanted to objectify to know the extent of its current application [[6], [7], [8], [9]].

The objective of this study was to poll pediatric otolaryngologists with an interest in pediatric laryngology regarding their experience with injection medialization laryngoplasty (IML), thyroplasty, and reinnervation procedures to highlight the currently provided care and to reflect on changing clinical practices. Due to the recent mentioned changes and development in the past decade, we were curious to assess the presence of any changes and shifts in the current pediatric otolaryngology practices.

Section snippets

Survey description

An online survey was developed to determine the current practices of pediatric otolaryngologists in the management of unilateral vocal fold paralysis. A 10-questions survey was formatted for a web-based administration using Survey Monkey Inc. [10]. The survey consisted of 2 set of questions. Section A focused on the practice habits and different treatment selections (See Table 1). Section B was composed of 3 case scenarios with multiple choice answers (See Table 2).

Survey administration

Online distribution of the

Results

A total of 28 respondents reached out with their answers, corresponding to a 47% response rate. For unknown reasons, 1 respondent out of 28 did not respond to Clinical cases number 1 and 3, explaining the total number of 27 responses in the result reporting.

Discussion

After analysis of our results, we are able to conclude that two significant shifts in practice seem to appear according to those polled. These shifts in practice are extremely interesting and demonstrate the acquisition of new skills and procedures in the management and treatment of vocal fold paralysis by the pediatric otolaryngologists.

First of all, laryngeal reinnervation procedures have gained tremendous popularity amongst the subspecialty in the past decade. In fact, greater than 20% of

Conclusion

Two significant shifts in practice seem to appear according to those polled. First, ansa-RLN procedures are becoming more and more prevalent. Second, there is an increased use of office-based augmentation procedures in the treatment of pediatric VFP. Carboxymethylcellulose seems to be the most popular chosen material for IMLs. The variation of responses in management of VFP in the treated population definitely calls for a serious conversation on standardization of care and management algorithms.

Conflicts of interest

The authors do not have any conflict of interest.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Aknowledgments

The authors would like to thank all survey respondents.

References (14)

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The abstract of this paper has been accepted for a poster presentation at the upcoming American Society of Pediatric Otolaryngology (ASPO) meeting – 2018.

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