Case Report: Right phrenic nerve palsy following esophageal atresia repair: a report of two cases and literature review of management strategies

Background: Phrenic nerve palsy (PNP) following esophageal atresia (EA) repair is an extremely rare complication with limited global experience. This report of two cases, integrated with a literature review, aims to synthesize available evidence to propose a structured management strategy. Case presentation: We describe two neonates who developed right PNP after type III EA repair. Case 1 was diagnosed with right phrenic nerve palsy on postoperative day (POD) 7 via chest x-ray and ultrasound and achieved full recovery after five weeks of non-invasive respiratory support. Case 2 was diagnosed on POD 14; after six weeks of failed conservative management, the infant underwent successful diaphragmatic plication. Both infants had favorable outcomes at follow-up. Conclusion: Based on the present cases and a review of all documented literature, we recommend a stepwise approach for managing post-EA repair PNP: Preventively, intraoperative phrenic nerve monitoring should be considered during EA/TEF repair to reduce the risk of iatrogenic injury. For diagnosed cases, we suggest early diagnosis using bedside x-ray and ultrasound, followed by an initial trial of 4-6 weeks of non-invasive support, with diaphragmatic plication reserved for weaning failure.