REVIEW

CURRENT
OPINION Recurrent laryngeal nerve reinnervation: is this the
standard of care for pediatric unilateral vocal
cord paralysis?
Maria Catalina Espinosa a and Julina Ongkasuwan b,c

Purpose of review
Ansa to recurrent laryngeal nerve reinnervation, otherwise known as a nonselective laryngeal reinnervation
(NSLR), is growing in popularity for the management of pediatric unilateral neuronal vocal fold movement
impairment (VFMI). In this chapter, we will review the current treatment options for neuronal VFMI and role
that NSLR plays in the treatment algorithm.
Recent findings
In 2018, Bouhabel and Hartnick published a survey of fellowship trained pediatric otolaryngologists and
found an increasing comfort level with NSLR. Respondents felt that NSLR resulted in favorable subjective
and objective postsurgical voice outcomes. Furthermore, NSLR may decrease the risk of aspiration in
children with neuronal VFMI. Although NSLR appears to work, the voice results are not perfect for all
children. Further work is being done to understand which preoperative variables, such as age, time from
injury, and preop laryngeal electromyography, may predict a better voice outcome.
Summary
A variety of treatment options exist for unilateral neuronal VFMI. Recent data and developments
demonstrate the effectiveness of reinnervation as a potential first-line surgical intervention in children with
unilateral neuronal VFMI.
Keywords
pediatric, recurrent laryngeal nerve reinnervation, vocal fold movement impairment

INTRODUCTION process or neuronal injury. Successful management

Unilateral vocal fold movement impairment (VFMI)
in children is most commonly a result of iatrogenic
injury to the recurrent laryngeal nerve (RLN). The
resultant glottic incompetence may result in dys-
phonia, aspiration, or stridor. There are no clear
treatment guidelines for the management of pediat-
ric unilateral neuronal VFMI. Historically, manage-
ment has consisted of observation, injection
laryngoplasty, and laryngeal framework surgery.
Over the last decade there has been increasing inter-
est in nonselective laryngeal reinnervation (NSLR),
specifically ansa to RLN reinnervation, for the man-
agement of pediatric unilateral neuronal VFMI.
DIAGNOSTIC WORK-UP
VFMI encompasses any restricted or abnormal
movements of the vocal fold; however, this term
does not imply the cause of the impaired motion.
Nearly all causes of fold impairment can be attrib-
uted to a mechanical joint fixation, neoplastic
requires diagnostic methods such as direct laryngos-
copy, arytenoid palpation, or laryngeal electromy-
ography (LEMG) to differentiate between structural
versus neurological injury. Direct visualization with
laryngoscopy can help identify gross hypo or amo-
bility of the vocal fold [1]. The addition of arytenoid
palpation can detect physical limitations such as
crico-arytenoid subluxation, scarring of the interar-
ytenoid region, or posterior glottic stenosis. In con-
trast, LEMG can determine the neuromuscular
a
Department of Undergraduate Medical Education, Baylor College of
Medicine, bDivision of Pediatric Otolaryngology, Texas Children’s Hospi-
tal and cDepartment of Otolaryngology Head and Neck Surgery, Baylor
College of Medicine, Houston, Texas, USA
Correspondence to Julina Ongkasuwan, MD, FAAP, FACS, Pediatric
Otolaryngology, Texas Children’s Hospital, 6701 Fannin Street, Mark
Wallace Tower, Suite 640, Houston, TX 77030, USA.
Tel: +1 832 822 3250; fax: +1 832 825 9070; e-mail: julinao@bcm.edu
Curr Opin Otolaryngol Head Neck Surg 2018, 26:431–436
DOI:10.1097/MOO.0000000000000499

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Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

Pediatric otolaryngology
KEY POINTS
 Nonselective ansa-recurrent laryngeal nerve
reinnervation is an effective treatment option for
pediatric unilateral neuronal VFMI.
 Injection laryngoplasty and laryngeal framework surgery
are temporizing measures in the pediatric population, and
are ultimately unable to restore muscle bulk and tone.
 Recent advancements in reinnervation techniques
demonstrate the potential of NSLR as the preferred
medialization technique for unilateral neuroal VFMI
in children.
integrity of the laryngeal muscles and distinguish
neurogenic causes of immobility, such as the RLN
[2]. These initial diagnostic measures are key to
ensure proper management.
NON SURGICAL MANAGEMENT OPTIONS
Observation
Treatment options for children with neuronal VFMI
are often dictated by symptomatology. Minimally or
asymptomatic patients, such as those without respi-
ratory distress or severe dysphagia, may undergo
expectant observation for spontaneous recovery of
the RLN. A suggested surveillance period of 12–24-
month postinjury is recommended for spontaneous
resolution, though there has been variability in time
to recovery rates [3].
Observation with speech rehabilitation as
monotherapy has had some success in improving
glottic closure in children older than 12 years old
however, most studies report mixed perceptual and
objective improvements [3,4]. Although children
are more likely to experience spontaneous reinner-
vation as compared with adults, reported rates are
highly variable, ranging from 28 to 73% [5–7].
Observation alone proves problematic in symp-
tomatic children. Without further intervention, pho-
nation suffers and patients may remain at risk for
airway compromise and aspiration [8–10]. In the
largest pediatric cohort retrospective study of vocal
fold paralysis in children, only 26% of the population
studied experienced spontaneous resolution over
4 months [6]. Optimal and timely restoration of
the immobile fold is best for voice production, swal-
lowing, respiration, and overall quality of life [5,11].
Impact on quality of life
The multifaceted effects of a dysfunctional vocal
fold can negatively impact a child’s quality of life.
432 www.co-otolaryngology.com
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In addition to hindering airway functionality, dys-
phonia is particularly challenging for the pediatric
population as they are actively undergoing a stage of
accelerated physical, social, and emotional develop-
ment. Perceived ineffective phonation secondary to
uncompensated neuronal VFMI can lead to social
anxiety and decreased communicative effective-
ness, leading to poor social integration [12]. Diffi-
culty communicating needs can lead to depression,
social anxiety, and generalized frustration, disrupt-
ing school and family life [13].
Recent pediatric-specific adaptations of voice-
related quality of life surveys demonstrate the neces-
sity to evaluate the impact voice impairment has on
emotional, social, and functional development in
children [14]. Streamlining the process of rehabili-
tative procedures is paramount as advancements in
corrective cardiothoracic procedures, the leading
cause of iatrogenic VFMI, lead to a rise in neonatal
vocal fold injury [15].
Voice therapy
Voice therapy with a qualified speech language
pathologist can help children maximize efficiency
for voice. Therapy can also help alleviate symptoms
associated with compensatory mechanisms such as
secondary muscle tension dysphonia and supraglot-
tic phonation. In addition, post-medialization voice
therapy is occasionally needed to help children
become accustomed to their new voice.
SURGICAL INTERVENTIONS
Three main surgical interventions exist for symp-
tomatic children or when observation and speech
therapy are unsuccessful. All three options function
to medialize the paralyzed cord to improve glottic
closure, subsequently optimizing phonation, swal-
lowing, and pulmonary toilet [16].
Injection laryngoplasty
Injection laryngoplasty provides temporary relief of
glottic insufficiency through the injection of syn-
thetic material into the paralyzed vocal fold to
enhance midline positioning of the immobile cord.
Since the first Teflon injection in 1977 in the pedi-
atric population, this procedure has remained in
favor over the years due to perceived advantages
of being an outpatient, endoscopic procedure with
minimal anesthetic use [17]. Although laryngeal
injections are preferred by some practitioners to
mitigate VFMI symptoms, this intervention is only
a temporizing measure for spontaneous reinnerva-
tion with several disadvantages.
Volume 26  Number 6  December 2018
 Recurrent laryngeal nerve reinnervation Espinosa and Ongkasuwan
Disadvantage: duration
Injectable materials are variable in terms of dura-
tion, irritating to the native vocal fold tissue, and
may cause histopathological changes to the lamina
propria. The materials resorb over time, necessitat-
ing subsequent reinjections until spontaneous rein-
neveration is reached [18,20] This can become a
time-consuming process with five out of 13 patients
requiring continued injections with a mean time of
9.7 and 31.6 weeks in between injections [19,20].
Even the most durable of the commonly used injec-
tion materials, calcium hydroxylapetite (CAHA)
lasts for roughly a year. Repeated anesthetics are
suboptimal in children, especially those with
cardiopulmonary comorbidities.
Complications: irritation to native tissue
and histopathologic changes
Complications are rare but reported adverse events
include persistent superficial injection, migration of
injective material, foreign body reaction or extrusion,
and abscess formation secondary to injection trauma
[21,22]. CAHA is particularly problematic because of
the potential inflammatory response in the imma-
ture vocal fold [23,24]. Teflon had a brief rise in
popularity because it was easily injected however
has fallen out of favor due to reports of long-term
giant cell granuloma formation [24,25]. Possible
long-term sequelae of injectable materials are of par-
ticular concern for the pediatric population. The
search remains for an injectable material that mirrors
the biological profile of the vocal fold and does not
illicit the aforementioned complications.
Of the injectable materials available, the senior
author prefers carboxymethylcellulose (Prolarynx
Voice Gel or Renu Gel), as this material has shown
good outcomes in voice improvements and has a
safe biological profile with few reported complica-
tions. However, this material only lasts 1–2 months.
Other materials such as hyaluronic acid (Restylane
or Juvederm) and collagen (Cymetra) are not yet
approved by the Food and Drug Administration for
use in the larynx. In addition, collagen can be
technically difficult to use and inflammatory
responses have been noted with hyaluronic acid.
For failed reinnervation and glottic incompetence
for nonneuronal causes such as vocal fold scar or
posterior glottic insufficiency, the author will use
autologous fat in children.
Overall utility
Further, the utility of injection laryngoplasty only
benefits a subset of patients with midfold or anterior
glottic gaps. To manage larger glottic insufficiencies,
particularly posteriorly, the arytenoid must be
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medialized, which cannot be accomplished with
injection laryngoplasty alone. Manipulation of the
taut attachment of the vocal fold epithelium to
perichondrium requires surgical manipulation [17].
LARYNGEAL FRAMEWORK SURGERY
Type 1 thyroplasty is an open neck procedure which
allows for permanent vocal fold medialization.
Through a thyroid cartilage window, a synthetic
implant is externally inserted and medializes the
immobile vocal fold. This procedure is advanta-
geous over injection laryngoplasty as it is reversible
and does not alter fold elasticity. In addition, there
are less reported adverse events with the three most
widely used implant materials, Gore-Tex, cartilage,
and Silastic [3,26]. Although this modality boasts
fewer reported immunological reactions and pro-
vides permanent medialization, it is an invasive
procedure with greater technical challenges [27].
Disadvantages
In adults, laryngeal framework surgery is performed
on awake or lightly sedated patients under local
anesthesia, which is procedurally difficult in chil-
dren. The senior author favors external framework
surgery only on postpubescent children. This pro-
cedure is technically challenging in younger
patients because the patient must be able to phonate
intraoperatively to determine the optimal size and
position of the implant. If the surgeon is unable to
accommodate the implant within the vocal fold in
accordance with the patient’s active vocal move-
ments, success, and quality of the procedure suffers.
However, laryngeal framework surgery can be
accomplished with general anesthesia, a laryngeal
mask airway, and a flexible laryngoscope [27].
Like injection laryngoplasty, thyroplasty pro-
vides immediate results but are temporizing mea-
sures in children that require revisions to
accommodate their growing laryngeal anatomy.
Other disadvantages of static medialization include
the continued atrophy of laryngeal muscles and
changes in the malleability of the vocal fold. With
an implant, the physical movement of the paralyzed
vocal fold relies on the integrity of the inserted
material to make fixed contact with the opposite
cord to improve phonation, leading to laryngeal
muscle atrophy. Fold tension is therefore
unchanged and cannot help with pitch control [28].
Arytenoid adduction
Another disadvantage of thyroplasty is failure to
correct persistent posterior phonatory gaps. This
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Pediatric otolaryngology
requires an adjunctive artytenoid adduction, a mus-
cular stitch that rotates the arytenoid. Arytenoid
adductions are technically difficult and add addi-
tional time to the procedure [29].
Overall utility
Type 1 thyroplasty provides immediate improve-
ments in voice quality and airway function however,
deinnervation continues with subsequent atrophy of
thyroarytenoid muscle [30]. Preventing thryoaryty-
noid bulk loss and improvements in dynamic control
can only be achieved by reinnervation.
REINNERVATION PROCEDURES
Reinnervation is a surgical technique that has gar-
nered increasing attention in recent years. This
treatment modality directly addresses neuropathy
through the anastomosis of nearby functioning
nerves with the RLN to restore muscle bulk and tone
to the impaired vocal fold. Adjacent nerves used in
reinnervation include the ansa cervicalis, phrenic,
hypoglossal, and superior laryngeal nerve. Since the
first RLN reinnervation with the ansa cervicalis
(ansa-RLN) in 1924 in adults and in 2007 in chil-
dren, several reinnervation techniques have been
developed [27,31]. These strategies include nerve
muscle pedicles, neural implantation, primary anas-
tamosis, and selective reinnervation [3,32]. Despite
the variety of techniques that have been explored,
nonselective ansa-RLN reinnervation has had the
best results improving glottic gap closure, subjec-
tive, and objective improvements in dysphonia [32].
ADVANTAGES
NSLR provides a unique advantage over other surgical
interventions in its ability to re-establish muscle tone
and bulk [10]. All other surgical options rely on static
medialization of the impaired vocal fold to minimize
the glottic gap but do not contribute to improve-
ments in mucosal wave propagation and vocal fold
tension [33]. Reinnervation functions to partially
restore the natural properties of the impaired vocal
fold, allowing for greater posterior glottic closure,
improvements in thyroarytenoid bulk and elimina-
&&
tion of synkinesis [31–34,35 ,36–38]. This proce-
dure is a dynamic therapy that can restore the
height and rotation of arytenoid, providing greater
functionality and overall mobility of the vocal fold.
NSLR is also a technically feasible operation for most
otolaryngologists that requires minimal recovery and
post operative care [39]. Although it is an open pro-
cedure, incision sites are small and no drain is
required [40].
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Within the last 6 years, several studies have
shown beneficial outcomes of NSLR therapy in chil-
dren. In one of the largest pediatric retrospective
studies of VFMI, Zur and Carroll [11] found NSLR
had better and longer lasting acoustic and perceptual
voice improvements as compared with injection lar-
yngoplasty. Within the same year, a review of 15
studies comparing NSLR, injection laryngoplasty
and type 1 thyroplasty, NSLR was the most effective
at managing dysphonia in terms of sustainability and
technical ease [15]. Similar benefits were seen in a
study by Smith et al. [36] which gathered postopera-
tive data on voice quality and swallowing and found
improved parental perceptual voice ratings and reso-
lution of dysphagia to liquids in all children.
In addition to enhancing overall voice quality,
NSLR provides distinctive advantages in the pediat-
ric population. Reinnervation utilizes autologous
nerve donation, minimizing foreign body, and
inflammatory reactions within the vocal fold. With-
out foreign body introduction, the laryngeal struc-
tures are preserved, minimizing the need for
multiple revisions to accommodate the child’s
growing laryngeal anatomy. Moreover, this proce-
dure is conducted under general anesthesia and does
not require the cooperativity of the child for optimal
results [27]. In addition, reinnervation caters to the
greater neurogenerative potential in children. Stud-
ies have shown adults to have varying degrees of
success in neuroplasticity with patients younger
than 52 years with greater success [10,30]. Smith
&&
and Houtz [35 ] examined the correlation between
age of NSLR and time elapsed since injury in 1–21
year olds. Slight negative correlation with duration
of time to reinnervation and voice outcome how-
ever adults are the least successful.
DISADVANTAGES
The principle concern regarding NSLR is the time
from procedure to notable improvements in voice
quality. Reinnervation may take an average of 4.5
months until there is an increase in muscle tone great
enough to produce changes in voice quality [37]. To
mitigate this problem, injection laryngoplasty can be
used in the immediate postoperative period while the
neurorrhaphy heals. This highlights an additional
advantage to reinnervation, as it does not preclude
other medialization procedures. Another concern
with medialization is the neurocognitive effects of
anesthesia with prolonged surgeries in children
under the age of three [41]. In the senior author’s
experience, it is optimal to wait until the child is at
least 3 years old before NSLR is attempted, due to
concerns of prolonged anesthesia exposure on the
cognitive development in children under 3 years old
Volume 26  Number 6  December 2018
 Recurrent laryngeal nerve reinnervation Espinosa and Ongkasuwan
[42]. This time frame also allows for improvements in
other potential comorbidities such as bronchopul-
monary dysplasia. For older children, the observation
period is 12 months, much like in the adult popula-
tion. Despite these drawbacks, NSLR is emerging as
the most attractive option for permanent manage-
ment of pediatric unilateral VFMI.
RECENT FINDINGS IN RECURRENT
LARYNGEAL NERVE REINNERVATION
RESEARCH
In 2018, Bouhabel and Hartnick surveyed 59 fellow-
ship trained pediatric otolaryngologists to identify
current practice shifts in the management of unilateral
VFMI. They found 37% of respondents perceive rein-
nevation as a first-line intervention in teenagers and
22% in younger patients, with concurrent injection
medialization laryngoplasty. The authors attribute the
increasing popularity of NSLR to increased comfort
level with the procedure secondary to increasingly
&&
favorable subjective and objective outcomes [43 ].
In addition to managing dysphonia, NSLR may
improve persistent aspiration related to unilateral
VFMI. Zur and Carroll examined three pediatric
patients who underwent reinnervation for the sole
purpose of persistent aspiration management. Post-
operatively, all patients had resolution of chronic
aspiration at an average of 1 month earlier than the
resolution of concurrent dysphonic symptoms.
They conclude that improved glottic closure assists
with laryngeal protection of the airway and can
prevent chronic aspiration [44 ].
&&
Although there has been some success with
laryngeal reinnervation, further work remains to
determine pre operative variables to predict better
voice outcomes. Ongkasuwan et al. analyzed pre and
postoperative subjective and objective data of 17
pediatric patients with unilateral focal fold paralysis
who underwent ansa-RLN reinnervation. Variables
included age, time from injury, and preoperative
LEMG. In accordance with study by Smith et al. [36],
there was no correlation of age or duration of injury
to time of surgical intervention with outcomes.
Objectively, preoperative LEMG responses revealed
greater response in patients with electrical silence or
spontaneous potentials preoperative LEMG [45].
Future directions
Future research should focus on refining preopera-
tive determinants of favorable voice outcomes. Cur-
rent studies are limited by small sample sizes and
lack of continued follow-up after implementing
interventions. Next steps in research should focus
on larger sample sizes and continual observation to
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see how the voice changes overtime and with
puberty.
Recent advancements in the adult population
In the adult population, Mattsson et al. explored the
use of nimodipine as an adjunctive treatment in vocal
fold motion impairment. Previously, nimodipine has
been used in clinical trials focused on cranial nerve
injury in patients. They hypothesize that calcium
channel blockers such as nimodipine help with axo-
nal nerve regeneration by inhibiting calcium medi-
ated depolarization, increasing time for axonal
elongation. This study presents the first human
cohort with 2–4 months of adjunctive nimodipine
therapy with objective and subjective outcomes [46].
All patients experienced improvements in maximum
phonation time 12 months after injury and near
normal Voice Handicap Index at 36 months post-
injury. Despite these promising results, there was no
control group to determine if the potential additive
effects of nimodipine to NSLR surgery.
CONCLUSION
After the consideration of spontaneous recovery in
pediatric unilateral neuronal VFMI, nonselective
ansa-RLN reinnervation remains a favorable man-
agement option. The pediatric literature for all types
of therapy remain relatively scarce however, NSLR
offers many technical advancements in comparison
with other medialization techniques. There is a need
to standardize care and examine the literature for
the most promising option for the growing number
of children at risk and RLN reinnervation remains
the most pragmatic option.
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
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and nerve reinnervation. Int J Pediatr Otorhinolaryngol 2018; 109:115–118.
The study surveys fellowship trained pediatric otolaryngologists to examine most
recent shifts in clinical practice when treating symptomatic unilateral VFMI.
Notable findings include a recent movement towards nonselective ansa-RLN
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Volume 26  Number 6  December 2018