Congenital Cardiac Anesthesia Society
A Section of the Society for Pediatric Anesthesia.

EXPLANATION

Vocal cord dysfunction (VCD) is a relatively common complication after pediatric cardiac surgery and most often results from injury to the recurrent laryngeal nerve.^² The left recurrent laryngeal nerve is particularly vulnerable because of its course around the aortic arch, making procedures involving the aortic arch, ductus arteriosus, and ligamentum arteriosum higher risk.^² The reported incidence varies considerably depending on the procedure and how patients are screened, with VCD occurring in approximately one-third of children undergoing high-risk cardiac procedures and reported rates ranging from 18% to 56% among different procedure groups.^² VCD can result in a weak or hoarse cry, stridor, feeding difficulty, and impaired airway protection.^¹˒² Aspiration is an important concern and may be silent; among infants undergoing swallowing evaluation after congenital heart surgery.^¹

Diagnosis should be considered in children with a change in cry, stridor, difficulty feeding, coughing or choking with feeds, or unexplained respiratory symptoms following cardiac surgery.^¹˒² However, the absence of symptoms does not exclude vocal cord dysfunction or aspiration.^¹ Flexible laryngoscopy is commonly used to directly assess vocal fold movement and confirm the diagnosis.^² Laryngeal ultrasound can also be used as a less invasive screening method and may reduce the need for flexible laryngoscopy in some patients.^² Because vocal cord dysfunction is associated with swallowing abnormalities and silent aspiration, affected patients should also undergo careful feeding and swallowing assessment, with videofluoroscopic swallow study when indicated.^¹˒²

Treatment depends on the severity of symptoms and the child’s ability to safely feed.^³ Many cases can be managed conservatively because vocal fold function may recover spontaneously over the months following surgery.^²˒³ Conservative treatment may include feeding modifications, thickened feeds, nasogastric feeding, and swallowing therapy while awaiting recovery.^¹˒³ For patients with persistent unilateral vocal fold immobility and significant dysphagia or aspiration, injection laryngoplasty is an additional treatment option.^³˒⁴ During injection laryngoplasty, filler material is injected into the affected vocal fold to move it toward the midline, allowing the functioning vocal fold to achieve better glottic closure.^³˒⁴ This may improve airway protection and allow advancement of oral feeding while the recurrent laryngeal nerve is recovering.^³˒⁴ Injection laryngoplasty has been shown to be feasible and generally safe even in infants younger than one year. Patient selection should be individualized based on feeding impairment, aspiration risk, airway symptoms, and likelihood of spontaneous recovery.^³˒⁴

Paralysis of the contralateral vocal fold would result in bilateral vocal fold dysfunction and could worsening aspiration risk. Injection laryngoplasty does not alter the innervation of the vocal folds and so conduction would not be restored from this procedure.

REFERENCES

1. Narawane A, Rappazzo C, Hawney J, Clason H, Roddy DJ, Ongkasuwan J. Vocal Fold Movement and Silent Aspiration After Congenital Heart Surgery. Laryngoscope. 2022;132(3):701-705. doi:10.1002/lary.29817

2. Kenny L, McIntosh A, Jardine K, et al. Vocal cord dysfunction after pediatric cardiac surgery: A prospective implementation study. JTCVS Open. 2022;11:398-411. Published 2022 Jun 9. doi:10.1016/j.xjon.2022.06.003

3. Nelson L, Belsky MA, Meister KD, Balakrishnan K, Freccero A, Sidell D. Standardizing Management of Pediatric Vocal Fold Immobility After Cardiothoracic Surgery. JAMA Otolaryngol Head Neck Surg. 2026;152(4):409-415. doi:10.1001/jamaoto.2026.0001

4. Ayoub N, Balakrishnan K, Meister K, et al. Safety and effectiveness of vocal fold injection laryngoplasty in infants less than one year of age. Int J Pediatr Otorhinolaryngol. 2023;168:111542. doi:10.1016/j.ijporl.2023.111542