Highlight
• Recurrent laryngeal nerve (RLN) reinnervation yields substantial voice improvements in 90% of pediatric patients with unilateral vocal fold paralysis (UVFP).
• The largest single-center, single-surgeon cohort (n=102) confirms both perceptual and acoustic voice measures improve markedly.
• Prematurity, prolonged intubation history, and posterior intubation deficiencies are associated with less robust voice recovery.
• Aspiration and respiratory symptoms improve or resolve in most patients following RLN reinnervation.
Background
Unilateral vocal fold paralysis in children is a challenging clinical condition typically caused by recurrent laryngeal nerve injury during birth trauma, surgery, or prolonged intubation. It significantly impacts voice production, airway protection, and swallowing function, leading to dysphonia, aspiration risk, and respiratory difficulties. Treatment options historically have been limited; symptomatic voice therapy and injection laryngoplasty offer temporary improvements, but do not address underlying denervation. Reinnervation of the recurrent laryngeal nerve aims to restore neuromuscular function and improve vocal fold mobility and voice quality. While prior data are limited to small cohorts or case series, large-scale evidence regarding effectiveness and patient factors affecting outcomes remains scarce.
Study Design
This retrospective case series analyzed all pediatric patients undergoing RLN reinnervation for UVFP at a tertiary care children’s hospital from 2007 through 2025 under a single surgeon. The study included 102 patients, with detailed voice evaluations available on 71 (70%). Primary endpoints comprised perceptual voice evaluations (using GRBAS scale), patient-reported vocal handicap indices (pVHI), and acoustic measurements (Cepstral peak prominence). Secondary endpoints evaluated aspiration symptoms and dyspnea/stridor suggestive of synkinesis. The study also explored clinical factors—sex, gestational age, intubation history, and intubation-associated laryngeal lesions—associated with voice outcomes.
Key Findings
Among the 71 patients assessed for voice outcomes, 64 (90%) demonstrated moderate to dramatic improvement post-RLN reinnervation, with 53 showing dramatic improvement. Dramatic improvements corresponded with significant mean reductions in pVHI scores by 15.9 points and GRBAS scores by 3.0 points, indicating substantial enhancement in patient-perceived vocal function and clinician-rated voice quality. Acoustic voice analysis revealed an increase of 2.1 dB in Cepstral peak prominence values, with 67% of patients achieving near-normal or normal acoustic profiles. Aspiration affected 25% of patients preoperatively but resolved in 80% during follow-up. Dyspnea or stridor related to synkinesis was noted in a small subset (5%) but resolved in all cases post-reinnervation.
Factors negatively influencing voice outcomes included female sex, lower gestational age (more severe prematurity), history of prolonged intubation, and presence of posterior intubation deficiency—probably reflecting more extensive neurogenic or structural laryngeal injury. These findings emphasize the complexity of neurogenic recovery in vulnerable pediatric populations.
Expert Commentary
This extensive case series solidifies the role of RLN reinnervation as an effective, durable surgical intervention for pediatric UVFP, transcending prior small cohort limitations. The convergence of perceptual, patient-reported, and objective acoustic improvements affirms a robust multimodal benefit, critical for clinical decision-making. The impact of prematurity and airway injuries underpins the necessity for careful patient selection and counseling. Future work could explore adjunctive therapies or optimized timing in this cohort. Limitations include the retrospective design and potential selection bias given the single-surgeon, single-center nature, which might affect generalizability to other practice settings.
Current guidelines for pediatric laryngeal paralysis advocate RLN reinnervation as a viable reconstructive option when vocal fold motion does not recover spontaneously within months, particularly in cases jeopardizing airway protection or phonation. Biological plausibility rests on the premise that reinnervation restores functional motor endplate connections, preventing atrophy and enhancing glottic closure dynamics, thereby improving voice and swallowing safety.
Conclusion
The present study from Gobillot et al. provides compelling evidence that RLN reinnervation is an effective intervention in the management of pediatric unilateral vocal fold paralysis, achieving marked improvements in voice quality and airway function in the majority of patients. This approach should be considered early in appropriate patients to optimize functional recovery. However, clinicians must recognize factors such as prematurity and intubation-related laryngeal damage that may attenuate outcomes. Further prospective studies could refine patient selection and standardize rehabilitation protocols to maximize return of vocal fold function in this vulnerable population.
Funding and Clinicaltrials.gov
No specific external funding was reported for this retrospective analysis. Clinical trial registration details were not provided.
References
1. Gobillot TA, Carroll LM, Zur KB. Outcomes of Recurrent Laryngeal Nerve Reinnervation for Pediatric Unilateral Vocal Fold Paralysis. The Laryngoscope. 2026 Jul 13. PMID: 42443056.
2. Sulica L. Recurrent laryngeal nerve reinnervation in vocal fold paralysis: current practice and future prospects. Curr Opin Otolaryngol Head Neck Surg. 2020;28(6):386-392.
3. Johns MM, II. Reinnervation techniques for pediatric vocal fold paralysis. Curr Opin Otolaryngol Head Neck Surg. 2019;27(6):478-484.
4. Hartnick CJ et al. Pediatric laryngeal paralysis: Diagnosis and management. Otolaryngol Clin North Am. 2008;41(5):909-922.
