Standardizing Management of Pediatric Vocal Fold Immobility After Cardiothoracic Surgery

Importance: Unilateral vocal fold immobility (UVFI) is a common complication of cardiothoracic surgery in pediatric populations, yet no standardized treatment guidelines exist. The current literature supporting pediatric injection laryngoplasty (IL) has been limited by heterogeneity in patient populations, treatment approaches, and outcomes analysis. Objective: To implement a standardized, multidisciplinary protocol for managing pediatric UVFI after cardiothoracic surgery and describe recovery patterns and outcomes observed among patients treated with IL vs conservative approaches. Design, Setting, and Participants: This prospective cohort study was conducted at a tertiary care referral center and included patients who were undergoing cardiothoracic surgery involving the aortic arch at age 1 year or younger between August 2015 and September 2024. Data were analyzed from September 2024 to October 2024. Patients with adjusted age of 36 weeks or younger at the time of surgery or a preoperative diagnosis of dysphagia were excluded. Additional exclusion criteria removed patients who did not complete postoperative feeding evaluations due to clinical decline and those who underwent IL outside the initial admission after cardiothoracic surgery. Exposure: Injection laryngoplasty. Main Outcomes and Measures: The primary outcome was oral diet advancement at time of discharge after cardiothoracic surgery, which was defined by improvement in frequency, volume, or consistency of oral intake. Secondary outcomes included nasogastric feeding tube (NGT) requirements, rate of gastrostomy tube placement, and hospital length of stay. Results: A total of 128 patients (53 [41.4%] female and 75 [58.6%] male; median [IQR] age, 17 [6-87] days) were included. Of the 45 patients (35.1%) with UVFI, 17 underwent IL and 28 did not. More IL patients achieved oral diet advancement by discharge compared with non-IL patients (17 of 17 [100%] vs 18 of 28 [64.3%]; difference, 35.7%; 95% CI, 12%-54%). Fourteen IL patients (82%) were discharged with an NGT vs 18 (64%) non-IL patients (difference, 18%; 95% CI, -9% to 40%). The median (IQR) time to NGT removal for IL vs non-IL patients was 30 (24.5) days vs 58 (89.5) days (difference, -28 days), and the median (IQR) hospital length of stay for IL vs non-IL patients was 28 (14.0) vs 23 (19.5) days (difference, 5 days). Conclusions and Relevance: Implementing a clinical pathway for managing UVFI after cardiothoracic surgery may standardize treatment and outcome assessment. In this cohort study, IL patients more frequently achieved oral diet advancement during the immediate postoperative period than those treated conservatively. However, these groups differed in baseline clinical characteristics that were associated with treatment selection; therefore, the observed differences in outcomes cannot be attributed to treatment choice alone.