Pediatric vocal fold medialization with silastic implant: intraoperative airway management

Vocal fold immobility accounts for 10% of all congenital laryngeal abnormalities, second only to laryngomalacia. Acquired unilateral vocal fold immobility (UVFI) is generally due to surgical trauma. The problems associated with this condition include a breathy dysphonia, weak cough, and aspiration. Treatment involves observation, voice and swallowing therapy, and various surgical options. Medialization laryngoplasty with silastic implant (ML-s) is a very successful procedure with consistent results in the adult population. It is usually done under local anesthesia with sedation to allow the voice to be monitored during the procedure. The surgeon can then fashion a custom implant or use a specific prefabricated implant. Additionally, use of the flexible fiberoptic nasopharyngolaryngoscope (FFNPL) allows the surgeon to see the endolarynx during the procedure, thus avoiding overmedialization and airway obstruction. Children, however, do not tolerate such invasive procedures under local anesthesia and sedation, have much smaller airways and, therefore, present several problems when addressing this problem surgically. Management of the pediatric airway during ML-s can be achieved using a laryngeal mask airway (LMA) and the FFNPL. While this does not allow the voice to be assessed intraoperatively, appropriate medialization of the vocal fold can be judged via the FFNPL, and airway obstruction avoided. ML-s using the LMA and FFNPL was performed in two children aged 8 and 4 years old. Both had excellent voice results and no complications. The details of these cases are reported. The literature on treatment of UVFI in children is reviewed, and practical and theoretical issues discussed.