Symptomatic Vocal Cord Paresis/Paralysis in Infants Operated on for Esophageal Atresia and/or Tracheo-Esophageal Fistula Francesco Morini, MD, Barbara D. Iacobelli, MD, Alessandro Crocoli, MD, Sergio Bottero, MD, Marilena Trozzi, MD, Andrea Conforti, MD, and Pietro Bagolan, MD Objectives To describe the prevalence and pathogenesis of symptomatic vocal cord paresis/paralysis (VCP) in patients treated for esophageal atresia (EA), tracheo-esophageal fistula (TEF) or both. Study design Retrospective study of all patients treated for EA/TEF in our center (1995 to 2009). Patients with and without symptomatic VCP were compared for gestational age, birth weight, associated anomalies, referrals, long- gap EA (>3cm or 3 vertebral bodies), cervical esophagostomy, anastomotic leakage, length of ventilation, and major cardiac surgery. Prevalence or median (IQR) is reported. Results Of 174 patients, 7 (4%) had symptomatic VCP. Prevalence of referrals (5/7 versus 21/167; P = .0009), long gap (5/7 versus 41/167; P = .0146), previous cervical esophagostomy (5/7 versus 7/167; P < .0001), and anasto- motic leakage (3/7 versus 10/167; P = .0097) was higher, and ventilation longer (8.5 days [7.0 to 15.5] versus 6.0 days (5.0 to 7.0); P = .0072) in patients with VCP. Conclusions In infants treated for EA/TEF, VCP should be ruled out in case of persistent respiratory morbidity or, when present, cautiously monitored. Surgical risk factors should be actively controlled. Further studies are needed to define the prevalence of acquired and congenital VCP in patients with EA/TEF. (J Pediatr 2011;158:973-6). P atients operated on for esophageal atresia (EA) and/or tracheo-esophageal fistula (TEF) are at risk of associated respi- ratory and gastrointestinal morbidity, such as severe respiratory distress, recurrent aspiration pneumonia, failure to thrive, and dysphagia. Most of these morbidities are related to tracheomalacia and gastro-esophageal reflux associated with EA/TEF and its treatment. Vocal cord paresis/paralysis (VCP) is a well-known cause of respiratory morbidity in infants and children that may increase the risk of aspiration pneumonia because of impaired airway protection, swallowing difficulties, and gastro-esophageal reflux. 1,2 VCP may complicate cervical and thoracic surgery in both adults and children, because of in- jury to the vagus nerve or the recurrent laryngeal nerve. In adults who have undergone esophagectomy, the prevalence of VCP has been reported to be between 2% and 80%, depending on the surgical site (twice as high with a cervical approach compared with an intrathoracic approach) and on the surgeon’s experience. 3 In children, cardiovascular surgery, mainly patent ductus ligation, is the most common cause of post-surgical VCP, the prevalence ranging from 4% to 16%. 4-7 VCP is seldom reported in infants who undergo surgery for EA/TEF, but overall this complication has been underreported in the literature. 8-11 The aim of our study was to describe the prevalence of symptomatic VCP in a large cohort of patients operated on for EA/TEF and to define the role of potential pathogenetic factors. Methods We performed a retrospective review of all patients consecutively treated for EA/TEF between 1995 and 2009. Patients were grouped according to the absence or presence of symptomatic VCP, which was suspected when a patient presented persistent stridor, inspiratory dyspnea, and/or dysphonia/aphonia. In the case of suspected VCP, flexible laryngo-tracheo-bronchoscopy was performed by experienced pediatric otorhinolaryngologists with the patient breathing spontaneously, during inspiration and phonation. Vocal cord paresis was defined as incomplete abduction or adduction of one or both cords. Vocal cord paralysis was defined as complete immobility of one or both cords. Patients with and without VCP were compared for patient-related and treatment-related risk factors extracted retrospectively from their medical records. Patient-related factors included gestational age, birth weight, prevalence of long gap (>3 cm or vertebral bodies), and associated anom- alies and were used to determine the influence of abnormal development and tech- nical difficulty in the repair of EA. Treatment-related factors were used to determine the iatrogenic potential of treatment and included length of mechanical From the Neonatal Surgery Unit, Department of Medical and Surgical Neonatology, Bambino Ges u Children’s Research Hospital, Rome, Italy (F.M., B.I., A.C., P.B.); Interventional Radiology Unit, Department of Surgery, Bambino Ges u Children’s Research Hospital, Rome, Italy (A.C.); and Ear, Nose and Throat Unit, Department of Surgery, Bambino Ges u Children’s Research Hospital, Rome, Italy (S.B., M.T.) The authors declare no conflicts of interest. 0022-3476/$ - see front matter. Copyright ª 2011 Mosby Inc. All rights reserved. 10.1016/j.jpeds.2010.12.006 EA Esophageal atresia TEF Tracheo-esophageal fistula VCP Vocal cord paralysis/paresis 973