Vocal fold lateralization by percutaneous suture in children: A systematic review

Abstract

Objectives

Percutaneous vocal fold lateralization (PVFL) consists of external fixation with non-absorbable percutaneous suture of the vocal fold in a lateral position, under direct glottic visualization. The objective, through a systematic review, was to identify, select, evaluate, and synthesize the relevant evidence available to define whether PVFL is effective in avoiding the tracheostomy, as well as whether it is effective in allowing decannulation of children who have already been tracheostomized. Secondarily, vocal quality, complications and reversibility of the procedure were evaluated.

Methods

A systematic review was carried out based on the protocols described in the QUORUM/PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. The search strategy was carried out in the PubMed, Embase, Scopus, Web of Science, SciELO and VHL databases. The terms searched were a combination of indexed keywords using Boolean terms. Inclusion criteria: Primary studies that documented intervention outcomes in patients with BVFP; Studies including pediatric patients (defined here as <18 years of age); and studies with well documented postoperative follow-up. Exclusion criteria: Duplicate studies or with the same clinical data; articles that exclusively evaluated other surgical interventions, animal studies, reviews, or post-mortem studies; and studies with only patients with unilateral vocal fold paralysis.

Results

Among the patients under study, 80 cases, underwent the surgical technique under study, 41 of these (51.25 %) are male. The average age of patients undergoing the procedures ranged from 4 days to 10 years of age. Most patients already had preoperative comorbidities, generally cardiothoracic and laryngeal, followed by neurological causes. In 31 % of patients, only a high-flow nasal catheter was required and in 3 patients, transient orotracheal intubation was required. At the mean follow-up of 30 months [SD:24], around 20 of the 80 (25.6 %) patients presented some degree of dysphonia. However, there was no standardization of scales. Approximately 11 % of patients had some postoperative complication, with reintubation due to glottic edema being the most prevalent. There was only 1 death. Preoperatively, 38 % of patients with BVFP were tracheostomized. After the procedure, only 13 % of them still needed to continue with the tracheostomy during the postoperative period. However, 13 % of patients needed to remain with a tracheostomy. Among the tracheostomy patients, only 3 of them achieved return of vocal fold mobility. Among all patients, vocal fold mobility returned in 35 % of patients, with a total of 10 % of patients postoperatively. However, there were studies that did not report mobility due to the short follow-up. During follow-up, 6 patients required revision procedures to relocate lateralization suture or even due to skin abscess. Granuloma occurred in only 1 case. There was just one study reporting suture removal in 3 of its cases.

Conclusions

PVFL is an effective and safe procedure, either due to its high rates of avoiding tracheostomy and allowing decannulation, in addition to the potential for reversibility, or due to its low invasiveness, and can be used to treat PBPV in newborns and infants. However, more controlled studies are needed with longer follow-up of patients, with objective outcomes in the assessment of dysphonia and swallowing, in addition to assessing the incidence of long-term complications. Randomized, multicenter clinical trials are welcome to allow for a larger sample, comparing the efficacy and adverse effects of PVFL in relation to tracheostomy and other existing endoscopic procedures.