Botulinum Toxin for Pediatric Vocal Cord Dysfunction: A Case Series

Introduction Vocal cord dysfunction (VCD) in children is a rare but challenging airway disorder characterized by inappropriate vocal fold adduction during inspiration. In pediatric populations, it is often associated with neurologic comorbidities or refractory symptoms that do not respond to conventional therapies such as voice therapy or medical management. Botulinum toxin (BTX) has emerged as a potential therapeutic option due to its ability to transiently weaken overactive laryngeal muscles while preserving essential airway and phonatory function. However, evidence on its efficacy and safety in children remains limited. Methods We conducted a retrospective case series of 10 pediatric patients with confirmed VCD treated with BTX at a tertiary pediatric otolaryngology center between 2021 and 2024. All patients underwent pre- and post-treatment laryngoscopy with exercise laryngoscopy when feasible. Swallowing function was assessed via fiberoptic endoscopic evaluation of swallowing (FEES) or modified barium swallow studies. Results Ten patients (six female patients and four male patients; ages 12 days to 17 years) met the inclusion criteria. Primary indications included refractory inspiratory stridor (n = 10), severe dysphagia (n = 6), and failed conservative management. Four patients had tracheostomies for severe VCD-related obstruction; all were ultimately decannulated, although three required adjunctive airway procedures. BTX doses ranged from 10 to 50 units, titrated progressively over multiple sessions based on response and tolerance, targeting interarytenoid, thyroarytenoid, and lateral cricoarytenoid muscles. Post-treatment laryngoscopy showed improved glottic opening in nine (90%) patients. Non-tracheostomized patients showed marked improvement in dyspnea and swallowing function. Transient mild voice changes occurred in three patients but resolved within 4-6 weeks, and no aspiration events were observed. Conclusion BTX demonstrates significant efficacy in pediatric VCD management, particularly in cases with neurologic etiology and severe symptoms refractory to conservative therapy. Objective measures support its role in improving glottic function and facilitating decannulation in appropriately selected patients.