Preemies, PDA ligation, and vocal cord paralysis

A new study was published in the December 2010 edition of the journal Pediatrics addressing the risk of vocal cord paralysis after PDA ligation surgery for micropreemies (< 1000 g). The incidence is high: 54%.

What is vocal cord paralysis, why is this so common among preemies after PDA surgery, and why does it matter? To help answer these questions I enlisted the help of Dr. Russell Faust, a fantastic and very knowledgeable pediatric ENT (Ear, Nose, and Throat) specialist.

First of all, Dr. Faust was not surprised at the high incidence of vocal cord paralysis in this most recent study. While this study is small, the findings are in accordance with other research. One study from 2008 indicated an incidence of 67%. Basically, 1/2 to 2/3 of babies weighing less than 1,000 g will get a one sided vocal cord paralysis after PDA surgery.

What is a paralyzed vocal cord? There are two vocal cords and they meet in the middle of the trachea (windpipe). They move apart to let oxygen into the lungs and the flow of air across the cords creates our voice. The upside down slightly paler V shaped tissues in the photo above are the vocal cords, thanks Dr. Faust. When one is paralyzed it stays put in the middle (see the video below).

Why is this so common after PDA surgery (closing the patent ductus arteriosus)? The nerve that controls the left vocal cord (the recurrent laryngeal nerve) runs very close to the PDA. The surgeon is operating in a tiny area when a baby weighs less than 1,000 g, so injury is often not preventable. This is a recognized complication of the surgery and doesn’t mean than anything went wrong.

Why does the PDA need to be closed if the risk of vocal cord paralysis is so high? A PDA is an abnormal communication of blood between the left and right sides of the heart, causing the heart to work harder. For some preemies, this can affect oxygen levels or contribute to other problems. If a baby is doing well, then often the doctors can wait to see if the PDA will close by itself (it does sometimes). If a baby is too unstable for a “wait and see” approach, medication (indomethacin) can be used to close the PDA. If indomethacin doesn’t work or a baby can’t receive indomethacin (for example, they have necrotizing enterocolitis), the communication needs to be closed surgically.

What happens if the left vocal cord becomes paralyzed? According to Dr. Faust, there are several possible scenarios:

  • Hoarse voice, as one side of the vocal cords can’t move, the flow of air is compromised, affecting the voice.
  • Airway obstruction, which¬†can be a cause of sleep apnea or even affect the ability to exercise by reducing the flow of oxygen to the lungs (the paralyzed vocal cord basically narrows the airway).
  • Aspiration (stomach contents getting into the lungs). The vocal cords are the last line of defense protecting the lungs. If a baby refluxes and has vocal cord paralysis, aspiration is more likely to happen.

Should all babies who have PDA surgery see an ENT in follow up? Dr. Faust says only if there are problems, such as breathing issues (need to know if breathing problems due to vocal cord paralysis or to lung problems, such as bronchopulmonary dysplasia or asthma), possible sleep apnea, or suspected aspiration. Even if a baby just has a raspy voice, it is a good idea to have a pediatric ENT weigh in.

How is vocal cord paralysis diagnosed? The procedure is called a laryngoscopy, which involves passing a telescope through the mouth or nose into the airways to check if the vocal cords move back and forth. The video shows it nicely (one side stays put while the other moves…warning, an injection right into the vocal cords is performed in this video, and some might find it a little hard to stomach).

What can be done about a paralyzed vocal cord? Speech therapy can be helpful. Some children might need surgery to help open the paralyzed vocal cord. This doesn’t “fix” the nerve, but can open the airway if obstruction and breathing difficulties are an issue.

The bottom line? If your baby had PDA surgery (regardless of how much he weighed, but especially if he weighed less than 1,000 g) look out for any of the above problems. If you suspect an issue, ask for a referral to a pediatric ENT specialist.

Stay tuned for my next blog: tracheotomy and preemies (part two of my discussion with Dr. Faust).

Remember, this blog is not individual medical advice

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14 Responses to Preemies, PDA ligation, and vocal cord paralysis

  1. our Daniel’s left vocal cord is indeed paralyzed as a result of his PDA ligation. It has made for some difficulties for him and they had been predicted accurately by his NICU ENT. He has had difficulty with eating and swallowing, his laughter and cry have been virtually silent and he has had a whispery voice all which has improved as he has grown bigger and stronger over the years. The ENT predicted that he will never be able to be an acclaimed opera tenor but who cares. His mama much prefers the blues and rock and roll of which he has no problem singing along to on RockBand. :)

  2. Jennifer Gunter says:

    Thanks for posting! A raspy voice and MTV are a perfect match up!

  3. christine says:

    have you seen this article? thoughts?

    our sons PDA was closed with drugs, but when discussing the “what-if” of surgery, vocal cord paralysis was never mentionned by anyone on the NICu team!

  4. Jennifer Gunter says:

    Yes, the surgeons rarely discuss this complication. I think because they almost never see the kids in follow up they probably don’t apprecaite the magnitude of the issues. There is often little choice, if the surgery is needed, it is needed. However, parents still need to be warned and advised a head of time!!! Never and excuse not to have full disclosure.

    I saw the MSNBC article. There are definitely miracle babies, but I think the Stanford study is also important to consider.

  5. Eric Maule says:

    My Down’s Syndrome Grandaughter suffers from vocal cord paralysis post PDA surgery. Now their saying (almost 2 years later) that they think she’s suffering from aspiration, and they want to give her a trachotomy and feed her through a tube for the rest of her life!! Is this really the only option??????

  6. Pingback: The Why of Silent Aspiration, or Sam Didn’t Get Away Unscathed « bejogram

  7. I have to side with what Jennifer said. In the grand scheme of things back when my now 9 year old had the ligation in the NICU, the complication of left vocal cord paralysis was the last thing on our minds. He was in congestive heart failure his PDA having failed to close after three rounds off indocin. He was literally drowning.
    You can view a recent video of him here where he engages in a rather silly song and dance but appreciate the sound and quality of his 9 year old voice…while singing a silly song…

  8. Pingback: When your child is sick, sometimes all you can do is cry | The Preemie Primer Guide from Dr. Jen Gunter

  9. Kristen says:

    My 3 yr old daughter Grace was a 25 week preemie that had the PDA surgery-there was never any mention of the possibility of the vocal cord damage, but at the time you can’t care about that, because your child’s life is in danger! However, because of the lack of importance placed on the vocal cord paralysis after the surgery, she severealy aspirated and almost died after leaving the hospital. 3 years later, she still has a very raspy voice, aspirates on thin liquids, and we have been told there is nothing that can be done. We also weren’t told the vocal cord was paralyzed due to the surgery until we were seen at a different hospital. There needs to be more research and more options available to repair the damage done to the vocal cords!

  10. SJP says:

    I am a 17 year old girl and was born a preemie.I have lived with a raspy voice for over 17 years now.Hopefully in the future there would be a breakthrough segury to fix this condition.

  11. Kristin Kyun says:

    My ex 23 weeker weighed 14 oz. (410 grams) at birth. He had a PDA ligation 3 weeks after birth. During his NICU stay, he did have issues drinking a bottle and we were told it was normal suck/swallow issues of a micro preemie. One month after being discharged from our 170 day NICU stay, my son started having issues eating. We took him immediately to the NICU and it was determined that he was aspirating everything he drank. Immediately, we had a g-tube put in. A month later his pulminologist heard his raspy cry and wanted to do the scope himself. It was then determined that my son had a paralyzed vocal cord (direct result from his pda ligation). He had the paralyzed vocal cord the entire time and the NICU we were in passed him on the swallow study before going home. In the beginning, we were told that the vocal cord paralyzation was a side effect of the pda ligation and very common in babies under 1000 grams. We knew this would probably happen with our son. The frustrating part is that our 3rd NICU, Children’s Hospital, passed him on the swallow study, never checked for this prior when I brought up the feeding issues and they basically told me it could not be from the pda ligation. A pulminologist and Neo both ruled that his paralyzation was a direct result of the pda ligation due to the raspy, quiet voice since he had the ligation and his issues eating. PLease don’t let the hospitals push the trach on any baby if there is aspiration. Have a bronchoscopy done and ask about a g-tube. My son is now 19 months (15 adjusted) and finally starting to eat some stage 1 baby foods. His right vocal cord is compensating now for the left and closing off. There is hope!

  12. KAB says:

    I had PDA surgery as a preemie in the early 80′s, resulting in unilateral vocal cord paralysis. I have had 4 surgeries (first one at the age of 16), i am planning on having another surgery within the next 6 months. I have tried my best to not let my soft, whisperer voice define me as a person. It is very tiring and often upsetting getting asked everyday if you are “sick” or “why you talk like that”. I hope the newer generation of babies have better options than I did. Don’t get me wrong, I know that without the surgery I would have probably died as a result of premature birth. I thank God everyday. It hard not to want to have a “normal” voice.

  13. Colleen says:

    I’m a 17-yr-old female, born 3months 11days early, weighing 1lb, 6oz then just 11oz. I had open heart surgery (PDA valve) at 3. I’ve had a raspy/hoarse/low voice all my life (since then) and went through speech therapy, but other than the surgery, no major complications. I found this article very interesting, I always wondered why my voice was like this.

  14. Colleen says:

    I’m a 17-year old female, was born 3.5 months early, lowest weight was 11 ounces, had a PDA ligation at 3 years old + heart murmur, and I have a hoarse/raspy voice. My mom said it was vocal scarring from the tubes that were down my throat for months, but this article makes a lot more sense… either way, I am beyond thankful that I am healthy and ‘normal’, and I have no intention of trying to fix my voice in the future if the opportunity arises. I like to think that it makes me unique, even though I sound like I have a sore throat/guy voice/can’t sing ;)

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