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\begin{document}

\title{Letter to the editor in reference to: Vocal cord paralysis secondary to
vincristine treatment in children: A case series of seven children and
literature review.}



\author[1]{Henricus Hundscheid}%
\author[1]{Hanneke Bruijnzeel}%
\author[1]{Justin  Swartz}%
\author[1]{Remco de Bree}%
\author[2]{Peter Hoogerbrugge}%
\author[3]{Arnold Bittermann}%
\affil[1]{University Medical Centre Utrecht}%
\affil[2]{Princess Maxima Center for Pediatric Oncology}%
\affil[3]{Wilhelmina Children's Hospital University Medical Centre}%


\vspace{-1em}



  
  \date{May 22, 2024}


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Dear Sir,

With great interest we read the article by Godbehere \emph{et al} on
vincristine (VCR)-induced vocal cord paralysis (VI-VCP) in pediatric
patients.\textsuperscript{1} The subject is clinically relevant and the
authors provide a practical algorithm for diagnosing and treating
VI-VCP. We strongly support early ENT referral following stridor in
children to assess for potentially life-threatening complications of VCR
administration.\textsuperscript{2} Our recently published case report
and literature review (in Dutch) have found similar type and onset of
symptoms.\textsuperscript{1-2}

In a recent review (published in Dutch literature, see \textbf{Table 1}
) we summarized 22 studies including 45 patients, and we, remarkably,
found some data that were slightly contrasting with findings of
Godbehere \emph{et al.} \textsuperscript{1} First, we found that 11 out
of 45 children between 5 and 17 years of age presented with VI-VCP,
which suggests that airway obstruction might also affect older children
following VCR administration. For example, one 16-year-old and one
17-year-old child needed ICU management and intubation respectively
following VCR treatment. Six of the seven cases (85\%) described by
Godbehere \emph{et al} \textsuperscript{1} presented with bilateral
vocal cord paralysis, which suggests that this is more common than
unilateral paralysis. In contrast, we found that 26 out of the 35 cases
(74\%) that reported laterality presented with bilateral vocal cord
paralysis. VI-VCP laterality was not reported in 11 cases, which could
further affect this prevalence. Report of relatively more unilateral
paralysis could consequently result in lower (overall) indication of
invasive airway management.

Remarkably, in contrast to Godbehere \emph{et al} \textsuperscript{1} we
found that dose reduction resulted in reversion of paralysis in four
cases. Complete cessation of therapy might therefore not be needed in
all cases (contrasting findings of Godbehere \emph{et al}
\textsuperscript{1}. In addition, we retrieved six cases that showed
partial recovery and even two cases showing no recovery.

We also found (\textbf{Table 1} ) that respiratory support is not always
needed to facilitate VCR continuation: 10 children with bilateral vocal
cord palsy received VCR dose reduction and did not need invasive airway
management. One 7-year-old child with bilateral vocal cord palsy even
continued VCR at full dose. Finally, we found 3 cases receiving
tracheostomy as airway management, but still required discontinuation of
VCR treatment, indicating that invasive airway management does not
always facilitate continuation of VCR treatment.

In conclusion, we agree with Godbehere \emph{et al}
\textsuperscript{1}that awareness of this potentially life-threatening
complication is essential. Maybe our Table 1 could facilitate
implementation of treatment decision (trees) in patients suffering from
VI-VCP.

\textbf{References} :

Godbehere J, Payne J, Thevasagayam R. Vocal cord paralysis secondary to
vincristine treatment in children: A case series of seven children and
literature review. Clin. Otolaryngol. 2021;46:1114-1118.

J.E. Swartz, H.P.H. Hundscheid, H. Bruijnzeel, \emph{et al}
.~Vincristine-induced vocal cord paralysis: a rare but potentially
life-threatening complication, Ned Tijdschr Oncol 2021;18:16-21.

\textbf{Hosted file}

\verb`VCR induced VCP demographic table - FINAL.docx`  available at \url{https://authorea.com/users/482094/articles/568818-letter-to-the-editor-in-reference-to-vocal-cord-paralysis-secondary-to-vincristine-treatment-in-children-a-case-series-of-seven-children-and-literature-review}

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