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27. Laryngopharyngeal Dysfunction Following the Norwood Procedure
Margaret L Skinner, Lucinda A Halstead, Catherine S Rubinstein, Andrew M Atz, Scott M Bradley; Charleston, SC

Objective: Feeding intolerance after the Norwood procedure may prolong hospital stay, and has been implicated in interstage death. Operative damage to the left recurrent laryngeal nerve may contribute to swallowing dysfunction. We have initiated a program to evaluate the incidence and significance of recurrent laryngeal nerve and swallowing dysfunction following the Norwood procedure.
Methods: From 4/03 to 9/04, 27 neonates underwent a Norwood procedure; 25/27 had direct fiberoptic laryngoscopy and modified barium swallow (MBS) performed in the postoperative period. The remaining 2 patients died without undergoing evaluation. Study results were used to guide transition from nasogastric tube to oral feeding, need for thickened feeds, and placement of feeding gastrostomy tubes. The 25 study patients underwent operation at a median age of 7 days (range 3-19), and weight of 3.2 kg (range 1.9-4.2).
Results:Direct laryngoscopy showed left true vocal fold paralysis in 2/25 (8%), and a glottic gap in 2/25 (8%). MBS was abnormal in 11/25 (44%), showing aspiration in 6/25 (24%) and poor oromotor coordination in 9/25 (36%). Of the 2 patients with left true vocal fold paralysis, 1 had a normal MBS, and 1 had aspiration. Both patients with a glottic gap had aspiration. Among the 11 patients with an abnormal MBS, 6 (54%) had a gastrostomy tube placed prior to discharge. Hospital stay was longer in patients with an abnormal MBS: 31±11 vs. 22±8 days (P = 0.04). Nine patients had more than one MBS. Aspiration resolved in 4/6, and improved in 2/6 patients, from 2 weeks to 7 months post-Norwood procedure. The 25 study patients were discharged from the hospital alive (overall hospital survival 25/27 = 92%). Seventeen were taking formula or breast milk by mouth, 2 thickened oral feeds, and 6 gastrostomy feeds. There has been 1 sudden death prior to second stage palliation, in a patient with pharyngeal penetration, discharged on oral feeds.
Conclusions: Following the Norwood procedure, swallowing dysfunction was seen in 44% of patients, and resulted in increased resource utilization. Left recurrent laryngeal nerve injury, seen in 8% of patients, was an uncommon cause of swallowing dysfunction. Further study is required to determine other etiologies. Systematic evaluation of swallowing function allows appropriate tailoring of feeding and placement of feeding gastrostomy tubes, and may contribute to decreased hospital and interstage mortality.

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