Pediatric Ansa to Recurrent Laryngeal Nerve Reinnervation

Video Type: CVideo
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Author: Julina Ongkasuwan
Published:
Specialties: Otolaryngology, Pediatric Surgery
Schools: Baylor College of Medicine/Texas Children's Hospital
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Basic Info

The procedure shown in this video is a pediatric ansa to recurrent laryngeal nerve reinnervation. It is performed with a concurrent laryngeal electromyography and injection laryngoplasty.

Editor Recruited By: Sanjay Parikh, MD, FACS

DOI: http://dx.doi.org/10.17797/7jjbn56ca3

Advanced

Procedure

Vocal fold paralysis in children can lead to aspiration as well as a weak breathy voice. Treatment options in young children are limited. Framework surgery may have to be revised as they grow and injectable materials are not permanent. The ansa to recurrent laryngeal nerve reinnervation procedure has shown promise in restoring vocal fold closure for these children. The first published report was by Dr. Smith et al. in 2008. It is important to note that the procedure helps to restore tone, bulk, and position of the vocal fold. Ansa to recurrent laryngeal nerve reinnervation does not restore vocal fold movement.
Smith ME, Roy N, Stoddard K. Ansa-RLN reinnervation for unilateral vocal fold paralysis in adolescents and young adults. Int J Pediatr Otorhinolaryngol. 2008 Sep;72(9):1311-6.

Indications

Unilateral vocal fold paralysis

Contraindications

bilateral vocal fold paralysis, airway obstruction, cricoarytenoid joint fixation

Instrumentation

Setup

1.The laryngeal electromyography and injection laryngoplasty are performed under spontaneous ventilation with the bed at 90 degrees.
2.The reinnervation is performed with the table at 180 degrees to allow for crosstable microscope work.

Preoperative Workup

A laryngoscopy with or without stroboscopy should be performed to identify vocal fold paralysis. The patient should also be carefully assessed for vocal fold sulcus or posterior glottic scar as well as cricoarytenoid joint fixation prior to performing the reinnervation. Pre-operative voice recordings and voice measures are also obtained. Children should be assessed for cardiopulmonary disease, especially bronchopulmonary dysplasia in former premature children. At this time, we wait 2 years from the time of nerve injury before offering laryngeal reinnervation. This allows for any spontaneous recovery of nerve function as well as lung maturation. However, the potential neurocognitive risks associated with anesthesia under age 3 should also be discussed with the parents.

Anatomy and Landmarks

The incision is made in a relaxed skin tension line off midline just below the cricoid. The ansa cervicalis will be identified deep the omohyoid, on the carotid sheath. The recurrent laryngeal nerve is identified beneath the thyroid gland in the tracheoesophageal groove.

Advantages/Disadvantages

Laryngeal reinnervation can provide a permanent improvement in glottic closure for young children. However, it can take on the order of months to hear improvement in voice.

Complications/Risks

Pain, bleeding, infection, scar, unhappiness with voice result. It is important to note that this procedure does not preclude the ability to undergo other medialization procedures in the future if the patient or family is unhappy with the voice result.

Disclosure of Conflicts

Pain, bleeding, infection, scar, unhappiness with voice result. It is important to note that this procedure does not preclude the ability to undergo other medialization procedures in the future if the patient or family is unhappy with the voice result.

Acknowledgements

Marshall Smith, MD for his generous teaching. Jennifer Dang, MD and Micheal Yim, MD for patiently holding the scope throughout the filming of the procedure.

References

1.Smith ME, Houtz DR. Outcomes of Laryngeal Reinnervation for Unilateral Vocal Fold Paralysis in Children: Associations With Age and Time Since Injury. Ann Otol Rhinol Laryngol. 2015 Nov 8. http://www-ncbi-nlm-nih-gov.ezproxyhost.library.tmc.edu/pubmed/26553660
2.Zur KB, Carroll LM. Recurrent laryngeal nerve reinnervation in children: Acoustic and endoscopic characteristics pre-intervention and post-intervention. A comparison of treatment options. Laryngoscope. 2015 Aug 8 http://www-ncbi-nlm-nih-gov.ezproxyhost.library.tmc.edu/pubmed/26257068
3.Smith ME. Pediatric ansa cervicalis to recurrent laryngeal nerve anastomosis. Adv Otorhinolaryngol. 2012;73:80-5. http://www-ncbi-nlm-nih-gov.ezproxyhost.library.tmc.edu/pubmed/22472234
4.Zur KB. Recurrent laryngeal nerve reinnervation for unilateral vocal fold immobility in children. Laryngoscope. 2012 Dec;122 Suppl 4:S82-3 http://www-ncbi-nlm-nih-gov.ezproxyhost.library.tmc.edu/pubmed/23254614
5.Smith ME, Roy N, Houtz D. Laryngeal reinnervation for paralytic dysphonia in children younger than 10 years. Arch Otolaryngol Head Neck Surg. 2012 Dec;138(12):1161-6. http://www-ncbi-nlm-nih-gov.ezproxyhost.library.tmc.edu/pubmed/23247235
6.Smith ME, Roy N, Stoddard K. Ansa-RLN reinnervation for unilateral vocal fold paralysis in adolescents and young adults. Int J Pediatr Otorhinolaryngol. 2008 Sep;72(9):1311-6. http://www-ncbi-nlm-nih-gov.ezproxyhost.library.tmc.edu/pubmed/18586331

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