A New Standard for Pediatric Vocal Fold Immobility After Cardiac Surgery: Improving Outcomes Through Injection Laryngoplasty

Introduction and Context

Unilateral vocal fold immobility (UVFI) remains one of the most significant and frequent complications following pediatric cardiothoracic surgery, particularly procedures involving the aortic arch. The recurrent laryngeal nerve, which controls the movement of the vocal folds, follows a complex anatomical path that loops around the aorta, making it highly susceptible to injury during corrective cardiac procedures in neonates and infants. When this nerve is damaged, the resulting vocal fold paralysis can lead to a weak, breathy cry, but more critically, it results in an unprotected airway. This often leads to dysphagia (difficulty swallowing) and aspiration, where food or liquid enters the lungs, potentially causing pneumonia and significantly delaying the infant’s recovery.

Historically, the management of UVFI in this vulnerable population has been marked by significant heterogeneity. Some centers preferred a “wait and see” approach, hoping for spontaneous nerve recovery, while others moved toward early intervention with injection laryngoplasty (IL). However, a lack of standardized protocols has made it difficult to compare outcomes or determine the true efficacy of early surgical intervention. The publication of a new multidisciplinary protocol in JAMA Otolaryngology–Head & Neck Surgery marks a pivotal shift toward standardizing care for these high-risk patients, aiming to bridge the clinical gap between cardiac surgery and long-term developmental success.