Operative Approach: Recurrent Laryngeal Nerve Reinnervation

Laryngeal reinnervation may be accomplished in children using the traditional open neck approach; however a transaxillary endoscopic robot-assisted laryngeal reinnervation procedure has been reported as well [82]. Experienced phonosurgeons accomplish the open neck operative technique in less than 2 hours. Typically, no drain is required and the patient is discharged on the day of surgery.

Voice and swallow benefits from laryngeal reinnervation emerge after at least 3 months, and there is typically a gradual improvement over the ensuing 18 months. When the voice begins to strengthen, it is typically due to improved glottic closure. When that occurs, patients who had preoperative aspiration and swallowing difficulties would undergo a repeat clinical and/or radiographic assessment of their swallowing function to see if any restrictions on a thin liquid diet can be lifted. A reduction in pVHI averages 15 points more in post-reinnervation patients compared to those patients who chose injection laryngoplasty. Vocal range (measured in semitones) is greater post-reinnervation compared to injection, and the stability of fundamental frequency (measured through jitter) is significantly reduced for reinnervation patients compared to the injection patients. Cartilaginous positioning is improved in the majority of patients, but it is not consistent across cartilaginous features of arytenoid position, arytenoid height, arytenoid rotation, or arytenoid mobility during phonation [35] (Fig. 25.2).

Steps

1. 1.
   
   
   

   Confirm vocal fold paralysis through laryngeal electromyography and laryngoscopy.

   
   
    
   
   
2. 2.
   
   
   

   Make a curvilinear incision on the affected side, centering incision over the medial belly of the sternocleidomastoid (SCM) muscle.

   
   
    
   
   
3. 3.
   
   
   

   Skeletonize the SCM, and identify the omohyoid as it courses medially.

   
   
    
   
   
4. 4.
   
   
   

   Retract the omohyoid inferiorly and anteriorly (Fig. 25.3).

   
   
    
   
   
5. 5.
   
   
   

   Dissect the ansa cervicalis along the internal jugular vein. Once the loop of the ansa cervicalis is identified, dissect the more medial branches as possible donor nerves (Fig. 25.3).

   
   
    
   
   
6. 6.
   
   
   

   Dissect inferiorly to the thyroid gland in search of the recurrent laryngeal nerve. Ensure preservation of the parathyroid glands that may be coursing inferiorly.

   
   
    
   
   
7. 7.
   
   
   

   Elevate the strap muscles to form a tunnel to bridge the lateral and medial compartments. Placing a ¼ in. Penrose may be useful to retract the strep medially or laterally depending on the exposure (Fig. 25.4).

   
   
    
   
   
8. 8.
   
   
   

   Stimulate the donor nerve to ensure presence of electrical activity.

   
   
    
   
   
9. 9.
   
   
   

   Section donor nerve and the recurrent laryngeal nerve. Use one or two epineural sutures (9-0 ethilon BV-100-4 monofilament) placed in an end-to-end manner utilizing microscope (Fig. 25.5). Apply Tisseel over the anastomosis.

   
   
    
   
   
10. 10.
    
    
    

    Return strap muscles to their natural position.

    
    
     
    
    
11. 11.
    
    
    

    Irrigate the wound, and close with subcuticular sutures. No drain is needed.

    
    
     

Summary

The prevalence of dysphonia in the pediatric populations ranges from 6% to 53% [83, 84] with vocal fold paralysis among the top three most common disorders. Whether unilateral or bilateral, patients with vocal fold immobility disorders experience compromise in their quality of life and report poor voice and swallow skills. Due to increased risk for underlying vocal fold paralysis, children with tracheoesophageal fistula or Charcot-Marie-Tooth disease should have laryngeal examination. Because of the high risk for vocal fold immobility following cardiac surgery, these patients should be carefully assessed before and after surgery.

Fiberoptic laryngoscopy remains the standard assessment tool for vocal fold immobility, but there is emerging success of ultrasound imaging [70, 85] to reliably check laryngeal function. The use of ultrasound to determine presence of vocal fold immobility offers great promise to the international community. Confirmation of vocal fold immobility, however, is accomplished with laryngeal EMG, which should be done in all patients prior to laryngeal nerve reinnervation or laryngeal framework surgery.

Team management of the child with vocal fold immobility is essential due to the coexistence of voice, swallow, and respiratory deficits which impact on the child’s social and academic opportunities. It is important to create a global treatment plan that encompasses both short-term and long-term solutions for children with vocal fold disorders. With appropriate management, these patients can achieve good voice and swallow function, affording them greater potential throughout childhood and adulthood.

Emerging and Evolving Concepts

Laryngeal reinnervation has been shown to be highly successful in children, whether done through the traditional hands-on open neck approach or robotic-assisted surgery. As Telehealth expands, laryngeal reinnervation may be possible in more remote regions of the world. Management of vocal fold immobility through use of electrical pacing units [86] may also be possible in the future for those pediatric patients who are not candidates for laryngeal reinnervation.