Surgery to find your voice: A Q&A with a pediatric otolaryngologist


When we’re in a noisy restaurant, it’s really difficult to hear my young niece speak. She can only talk very quietly, because she has a paralyzed vocal cord.

Like many children born very premature, the nerve going to her vocal cord was likely damaged when she had heart surgery soon after she was born. Her inability to be heard frustrates her, especially now that she is in school. However, a rare surgery may bring her the hope of a near-normal voice.

Stanford surgeons recently began performing laryngeal reinnervation surgery, which essentially rewires the paralyzed vocal cord with a new nerve supply. I recently spoke with Anna Messner, MD, a professor of otolaryngology and pediatrics who sees patients at Lucile Packard Children’s Hospital Stanford, about laryngeal reinnervation surgery.

What standard surgical procedures are used to treat unilateral vocal cord paralysis?

In general, the surgical procedures bulk up the paralyzed vocal cord to move it towards the midline of the body, making it easier for the other vocal cord to compensate and close. There are two standard surgeries. We can do injection laryngoplasty, where we inject a substance into the paralyzed vocal cord to thicken it. Unfortunately, this procedure often needs to be repeated multiple times, if it works at all. We can also insert a medialization implant in teenagers and adults, but this doesn’t work for growing kids. If we put an implant into a 2-year-old, it wouldn’t be an appropriate size when he is 10.

How does laryngeal reinnervation surgery work?

No matter what we do, we can’t make the vocal cord move. We can never make it perfect again. What we can do is hook up one of the other nerves in the neck to the recurrent laryngeal nerve that goes to the vocal cord. And that helps some new nerve fibers go to the vocal cord, making the vocal cord stronger and thicker. As a result, the voices on these kids improve significantly.

The surgery itself is fairly straightforward and only takes about an hour. The children typical go home the same day or just stay overnight, and they feel back to normal in a couple of days. But then we have to wait five to six months for the nerve fibers to grow before we can see real improvement in the voice. The only downside is that it takes a long time to see the effects of the surgery.

What inspired you to learn the laryngeal reinnervation procedure?

We have a large pediatric cardiac surgery program at Stanford, so we have quite a few patients with vocal cord paralysis. Most of our patients are born prematurely and need heart surgery, which can pull and damage the nerve that goes to the vocal cord on one side. After these surgeries, the damaged vocal cord starts working again in just over a third of the cases. But for the rest of the kids, the vocal cord remains paralyzed.

The standard surgeries just don’t work very well, so we’ve had a longstanding interest in finding alternatives. I saw Marshall Smith, MD, the medical director of the Voice Disorders Center at University of Utah, give a presentation on his clinical trials. So I observed him performing the reinnervation surgery about 1.5 years ago, and since then I’ve been performing the surgery. One of my colleagues at Stanford, Doug Sidell, MD, also performs the surgery.

How does the voice improvement impact the patients?

The voice improvement makes a huge impact on the children, especially in school. For instance, when the children are trying to read a story or give a presentation in front of the classroom, now they can actually be heard. The results are very encouraging. The surgery has the potential for huge, lifelong voice improvement.

Via Scope
Photo by Howard Lake


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