Endoscopic anterior-posterior cricoid split to avoid tracheostomy in infants with bilateral vocal fold paralysis

Introduction: Infants with bilateral vocal fold paralysis (BVFP) can present with stridor and respiratory distress necessitating tracheostomy. The endoscopic anterior-posterior cricoid split (APCS) with balloon dilation procedure has been described as an alternative to tracheostomy in these patients. Here, we report our institution's preliminary experience with APCS and evaluate patient factors that may predispose to the success or failure of this procedure in infants with BVFP. Methods: Electronic charts of patients who underwent APCS with balloon dilation at a single institution were reviewed for the following variables: patient demographics, comorbidities, etiology of vocal fold paralysis, symptoms at presentation, need for respiratory support, intra-operative findings, duration of intubation, perioperative medical treatments, subsequent airway management, and findings of follow-up evaluations. APCS was considered successful if the patient did not undergo tracheostomy. Results: Six patients underwent APCS with balloon dilation between August 2014 and October 2019. Four patients (66.7%) were male, and 5 of 6 (83.3%) were born full term. The etiology of vocal fold paralysis was idiopathic in four patients (66.7%) and associated with a neuromuscular disorder and hydrocephalus in the remaining two patients. Mean age at the time of the procedure was 10.3 weeks. Three infants (50%) avoided tracheostomy and had marked alleviation of airway symptoms. Three patients who required tracheostomy had more severe respiratory symptoms pre-operatively, requiring either intubation or positive pressure support. Among all patients, there were no mortalities in our series. Conclusion: APCS is safe and may be effective at the elimination of airway symptoms in select infants with BVFP, avoiding the need for tracheostomy, however more investigation is needed to establish its precise role in this patient population.