Characterization and Management of Paradoxical Vocal Fold Motion in Neonates: A Case Report

Introduction

Paradoxical vocal fold motion (PVFM) is characterized by abnormal adduction of the vocal cords during inhalation, leading to symptoms such as inspiratory stridor, feeding difficulties, and poor weight gain in infants [1]. Diagnosis is often challenging, particularly in pediatric populations, due to the nonspecific symptoms and overlap with other conditions. In infants, PVFM is poorly characterized, with limited data available on its incidence, clinical features, and optimal management strategies. The average reported onset is at 5.7–7 months, often presenting with inspiratory stridor and a potential association with weight <25th percentile [2,3]. Symptoms frequently mimic more common pulmonary or gastrointestinal conditions, and frequently coexist with asthma, GERD, chronic rhinitis, or psychiatric conditions, complicating diagnosis [2,3,5,6]. GERD is a commonly associated comorbidity, with prevalence estimates ranging from 18% to 71% [2]. Various proposed etiologies, including motor neuron injury, irritant-associated causes, and factitious disorder [1], contribute to diagnostic complexity.

There is currently no single, universally accepted guideline for diagnosing neonatal PVFM. Diagnosis typically relies on a combination of clinical suspicion, exclusion of other causes, and direct visualization via FFL. FFL remains the standard method for diagnosis, revealing abnormal adduction of the vocal folds in about 95% of infants [2–4]. Stridor is the most common symptom, present in up to 95% of cases [3]. Speech-language pathology interventions have shown promise in older pediatric populations, while spontaneous resolution has also been documented in both infants and children. Despite these insights, standardized diagnostic criteria and treatment guidelines are lacking.

There is limited understanding of how demographic variables such as race and sex influence PVFM presentation and outcomes. Some studies suggest a higher prevalence of pharyngeal abnormalities in racial minority groups and a female predominance among pediatric PVFM patients [3,5,7]. These factors, combined with the lack of definitive etiology, complicate clinical assessment, and long-term care planning.

This case report characterizes a rare presentation of neonatal PVFM in a term Hispanic male diagnosed at 18 days of life. It aims to contribute to the growing body of literature by detailing diagnostic indicators, multidisciplinary management strategies, and outcomes, while highlighting areas where further research is required.

Case Report

OUTCOME:

At hospital discharge, the patient was at the 16^th percentile for weight. At a 1-week follow-up, he was gaining weight with exclusive oral feeds of Enfacare, placing him around the 7^th percentile. By his 2-month wellness check, his weight had decreased to the 8^th percentile, though he was reportedly feeding well by mouth without signs of choking or gagging. During this time, his g-tube site began showing signs of granuloma formation and irritation. At around 3 months of age, while still using the g-tube, his weight had declined to the 4^th percentile; however, he had successfully graduated from speech and occupational therapy for feeding due to sustained oral intake. The g-tube site continued to irritate and interfere with tummy time, prompting further evaluation. An FFL on day 68 (50 days after diagnosis) confirmed resolution of his prior vocal cord dysfunction, and the ENT supported g-tube removal. The pediatrician and parents discussed the risks and benefits of removal, including the slight possibility of recurrent vocal cord dysfunction and the potential need to replace the tube if significant weight loss occurred.

Benefits of removal included improved comfort and the ability to resume tummy time, and the parents were eager to proceed. At the first follow-up visit after tube removal, at 4 months old, the patient was at the 3rd percentile for weight, which was reassuring given the stable trajectory. By 8 months of age, he had improved to the 5th percentile, showing a positive trend in growth. The patient’s complete growth charts for weight-for-age and length-for-age are included as Figures 1 and 2, respectively.

Discussion

This case highlights the diagnosis, management, and spontaneous resolution of neonatal paradoxical vocal fold motion (PVFM). While PVFM can resolve over time, the literature describes variability in resolution timelines and the need for further study, a challenge further complicated by small cohort sizes and limited long-term follow-up. One case series of 7 infants diagnosed with PVFM between 1 week and 19 months of age reported an average resolution time of 5.9 months after initiating anti-reflux therapy, with no observed correlation between age at diagnosis and time to resolution. Notably, an infant diagnosed at 7 days old presented with feeding difficulties, inspiratory stridor, and a hoarse cry – clinical features similar to our patient. However, that case also involved reflux and structural anomalies, including short aryepiglottic folds, mild epiglottic retroflexion, and vocal fold edema, supporting an irritant-associated etiology. Symptoms resolved after 1.5 months of anti-reflux therapy [2]. Based on these findings, our patient was started on famotidine at diagnosis, followed by a proton pump inhibitor (PPI) and head-of-bed elevation on day 40.

Speech-language pathology (SLP) has also been associated with symptom improvement and resolution in PVFM. In a cohort of older patients aged 8–18 years, an average of 3.7 SLP sessions led to resolution, with some patients achieving complete resolution at an average of 27 months after discontinuing therapy. This suggests that SLP can support recovery, although spontaneous resolution remains possible [1].

Although our patient’s flexible fiberoptic laryngoscopy (FFL) on day 18 showed no evidence of laryngopharyngeal reflux or laryngeal edema, gastroesophageal reflux disease (GERD) is commonly associated with PVFM, and anti-reflux therapy remains a first-line treatment [2,5]. For our patient, a trial of gavage-only feeding preceded the introduction of anti-reflux medications, following discussion with the family. Symptom improvement was noted by day 50 after diagnosis, 28 days after PPI initiation. Importantly, unlike other cases with similar symptoms and positive responses to PPI therapy, our patient did not have structural abnormalities or visible signs of reflux on FFL [2]. Thus, the underlying etiology of PVFM in this case remains uncertain.

Despite the absence of structural anomalies or clinical GERD, anti-reflux therapy remains a foundational approach in managing neonatal PVFM [2,5]. In older children, treatment strategies may also include respiratory retraining, laryngeal control therapy, or psychiatric intervention [1,5]. Therapy duration can be influenced by comorbid behavioral health conditions or prior upper-airway surgeries; however, symptom type and age do not appear to impact treatment length significantly [8]. The relative efficacy of speech therapy versus psychiatric intervention continues to be debated.

The association between race and pharyngeal abnormalities on FFL in PVFM patients is also under investigation. A cohort study of 96 pediatric PVFM patients (ages 0–21) found that racial minority patients exhibited significantly more pharyngeal abnormalities than non-Hispanic White patients [4]. However, the literature on the influence of race and sex on PVFM incidence, clinical features, and outcomes remains limited. Studies in pediatric PVFM suggest a female predominance ranging from 55% to 75% [3,5,7]. Age-related differences in presentation have also been noted, with infants being more likely to have PVFM identified during FFL and less likely to have comorbidities such as allergies, behavioral concerns, or shortness of breath compared to adolescents [4].

Conclusions

This case underscores the diagnostic and management challenges of neonatal PVFM, a rare and under-recognized condition. It highlights the importance of flexible fiberoptic laryngoscopy as a diagnostic tool and supports the use of anti-reflux therapy and nutritional support as effective management strategies. Beyond individual treatment, this case report contributes to a broader understanding of PVFM’s clinical presentation and natural course in neonates. Further research is essential to establish standardized diagnostic criteria, explore demographic variations, and refine treatment approaches for this unique patient population.