A retrospective review of infant-inducible laryngeal obstruction a subtype of paradoxical vocal fold motion: Evaluation and management

Introduction: There is a paucity of literature on pre-adolescent paradoxical vocal fold motion (PVFM), PVFM is a sub-type of inducible laryngeal obstruction. Studies typically focus on older patients, however the discovery of this entity in pre-adolescent pediatric patients has led to more questions about how this entity manifests differently and is treated differently in younger populations. Initially considered psychosomatic and commonly mistaken for asthma, PVFM etiology is now thought to be associated underlying neurologic conditions and may have irritant triggers with proposed mechanisms related to laryngeal hypersensitivity. Treatment is multimodal. Diagnosis is with flexible laryngoscopy and clinical exam but other modalities like functional endoscopic evaluation of swallow may provide more information than flexible laryngoscopy alone.

Methods: After obtaining IRB approval, a retrospective review of all charts of patients ages 0-18 months (pre-adolescent pediatric patients) who underwent flexible endoscopic evaluation of swallow and/or flexible laryngoscopy from 1/2013-8/2021 was performed. Twenty-four subjects diagnosed with PVFM were identified.

Results: The most common presenting symptom was stridor or coughing with feeds. 63 % were male, mean age at time of diagnosis was 3.4 months, and mean follow-up length was 11.4 months. Comorbidities included reflux (45 %), pulmonary diagnoses (25 %) and neurologic diagnoses (54 %). 16/24 subjects had otolaryngology diagnoses (laryngomalacia, tracheomalacia, subglottic stenosis, or ankyloglossia). 12/24 subjects were treated with conservative management such as anti-reflux medications or precautions. 33 % of patients treated with conservative management had complete symptom resolution. PVFM patients with neurologic comorbidities were more likely to require alternative feeding access (p < 0.05). All 11 subjects who required surgical feeding access had neurologic diagnoses. 5/10 of patients with neonatal abstinence syndrome (NAS) required alternative feeding means, and 40 % tolerated oral feeds after medical management of NAS.

Conclusion: Our findings suggest PVFM is most commonly seen in pre-adolescent pediatric patients with medical comorbidities. Healthy pre-adolescent pediatric patients with PVFM frequently improved with conservative management. The differential diagnosis of the stridulous infant should include PVFM. It is imperative to consider nutritional access in PVFM patients with neurologic comorbidities.