Endoscopic Airway Surgery

Hartnick CJ, Hansen MC, Gallagher TQ (eds): Pediatric Airway Surgery. Adv Otorhinolaryngol. Basel, Karger, 2012, vol 73, pp 101–104

Pediatric Supraglottoplasty

Art Ambrosio � Matthew T. Brigger

Department of Otolaryngology, Head and Neck Surgery, Naval Medical Center San Diego, San Diego, Calif., USA

Abstract

Laryngomalacia is the most common congenital laryn-

geal abnormality, as well as the most common cause of

stridor in infants. Laryngomalacia presents as a wide spec-

trum of disease from mild noisy breathing with feeding to

life- threatening airway obstruction and failure to thrive.

The stridor associated with laryngomalacia is generally

inspiratory in nature from supraglottic airway collapse.

Supraglottoplasty refers to a group of procedures used

for the surgical management of laryngomalacia. In this

chapter, the authors review laryngomalacia and describe

the surgical techniques of supraglottoplasty.

Laryngomalacia is the most common congenital

laryngeal abnormality as well as the most com-

mon cause of stridor in infants. Laryngomalacia

results from dynamic airway obstruction origi-

nating from abnormal supraglottic structures [1,

2]. Laryngomalacia presents as a wide spectrum

of disease from mild noisy breathing with feeding

to life- threatening airway obstruction and failure

to thrive. Anatomic configurations are variable

and include redundant arytenoid mucosa (‘flop-

pers’), short aryepiglottic folds (‘curlers’) with

retroflexion of the epiglottis or a combination of

both.

A postulated theory of etiology is that laryn-

geal tone and sensorimotor integrative function

of the larynx is fundamentally altered in affected

children [3]. The degree of alteration correlates

with disease severity, indicating that factors that

alter the peripheral and central pathways of the

laryngeal adductor reflex have a role in the eti-

ology of signs and symptoms of laryngomalacia.

The presence of Gastroesophageal reflux dis-

ease (GERD), neurologic disease, and low Apgar

scores are associated with increasing disease se-

verity. Sensorimotor integrative function is noted

to improve as symptoms resolve [3].

Regardless of etiology, GERD has been well

documented in association with laryngomala-

cia, with worsening of laryngeal edema subse-

quently worsening respiratory symptoms [4, 5].

Evaluation of GERD should take place in the pre-

operative setting and the effect of medical man-

agement determined prior to surgery.

The diagnosis of laryngomalacia includes a de-

tailed history of the description of the stridor, cy-

anotic/apneic events, exacerbating factors, as well

as its association with feeding. The stridor asso-

ciated with laryngomalacia is generally inspira-

tory in nature from supraglottic airway collapse.

Further, physical examination should initially

The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government.

Art Ambrosio and Matthew T. Brigger are military service members. This work was prepared as part of their official duties. Title 17 .S.C. 105 provides that ‘Copyright protection under this title is not available for any work of the United States Govern-ment.’ Title 17 U.S.C. 101 defines a United States Government work as a work prepared by a military service member or em-ployee of the United States Government as part of that person’s official duties.

102 Ambrosio · Brigger

evaluate the infant’s work of breathing and must

include awake fiberoptic flexible laryngoscopy to

evaluate for dynamic supraglottic collapse and its

causative factors [6]. Polysomnography may prove

useful in some children, particularly in the setting

of neurologic disease. Children with evidence of

dysphagia, particularly when aspiration symptoms

are reported should undergo a detailed swallowing

evaluation with video fluoroscopic evaluation or

functional endoscopic evaluation of swallowing.

Indications

• Failure to thrive, weight loss, or significant

feeding difficulty

• Recurrent cyanotic events

• Obstructive apnea

• Secondary cardiopulmonary pathology such

as pulmonary hypertension or cor pulmonale

Contraindications

None.

Anesthesia Considerations

General anesthesia is given with spontaneous

ventilation or endotracheal intubation based on

surgeon preference and degree of pulmonary

reserve.

Preparation

• Preoperative

– Symptoms are monitored through a trial of

anti- reflux therapy and thickening of feeds

– Consideration of a polysomnogram

– Flexible fiber- optic laryngoscopic video is

reviewed to plan operative strategy

• Intraoperative

– Dexamethasone i.v. is given at 0.5 mg/kg

– Direct laryngoscopy is performed to bring

supraglottic anatomy into view, followed by

bronchoscopy to evaluate for synchronous

airway lesions

– The surgical procedure is tailored to specific

anatomic issues identified on preoperative

flexible laryngoscopy. Specific interventions

include:

◆ Excision of redundant arytenoids mucosa for

‘floppers’. Specific methods include power ed

microdebrider, CO2/KTP laser, cold micro-

laryngeal instruments.

◆ Division of the tight aryepiglottic folds in ‘curl ers’.

Specific methods include cold microlaryngeal

instruments (author’s prefer ence), powered

micro debrider, or CO2/KTP laser

Procedure

• The child is placed into laryngeal suspension

with an operating laryngoscope (Lindholm

preferred by the senior author)

• The child is maintained in a plane of

spontaneous breathing anesthesia or a small-

caliber endotracheal tube is placed

• An operating microscope or 0° Hopkins

rod telescope is used for intraoperative

magnification.

• For redundant mucosa associated with aryte-

noid prolapse, ablation with a CO2 laser or

resection with a 2.9- mm laryngeal skimmer

blade is employed for controlled, sequential

removal (see online suppl. video 1).

• Aryepiglottic fold division is used via micro-

laryngeal scissors or CO2/KTP laser (see online

suppl. video 2).

• Intraoperative countertraction for visualiz-

ation may be performed by gentle use of

microlaryngeal forceps or a straight laryngeal

suction.

• Epinephrine- soaked pledgets are utilized as

necessary for hemostasis.

Pediatric Supraglottoplasty 103

• If a laser- based technique is utilized, laser

safety precautions for both the patient and the

operating room staff including covering the

child’s face/eyes with moist towels/eye pads are

essential

Postoperative Care

• The child may be extubated immediately or

on postoperative day one with admission to

the Pediatric ICU for continuous respiratory

monitoring

• Decadron 0.5 mg/kg is given every 8 h for 24 h.

• Restart anti- reflux medication, thickened

feeds, and anti- reflux precautions (e.g. head of

bed elevation, keeping of infant upright after

feeds for a period of 30– 40 min)

• Antibiotic coverage for a period of 7– 10 days is

recommended

Complications

• Potential complications include supraglottic

stenosis, persistent feeding difficulties includ-

ing aspiration, persistent airway obstruction

or laser- specific issues such as airway fires

• Postoperatively, transient new- onset aspir-

ation has been reported to occur in up to

28% of children [7]. Such aspiration seldom

requires more than a brief period of thicken-

ing the feeds.

Pearls

• Laryngomalacia is the most common cause of

stridor in the newborn; the choice of a tailored

supraglottoplasty in a select population can

have a profound effect in respiratory effort and

feeding

• A trial of anti- reflux medication and pre-

cautions will help to delineate nonoperative

from operative candidates in the preoperative

evaluation.

• Surgical intervention is based on a targeted

approach derived from a dynamic evaluation

of supraglottic collapse.

• Maintaining postoperative anti- reflux therapy

is recommended.

• A directed sufficient, but not overzealous

resection of tissue is important to alleviate

symptoms, but not cause supraglottic

stenosis. Unilateral supraglottoplasty has been

advocated to avoid postoperative supraglottic

scarring. In the author’s experience, judicious

resection bilaterally has proven safe and

maximally effective.

• Judicious supraglottoplasty is associated with

few complications and clinical improvement

in >85% of children undergoing the procedure

[3, 7, 8]

• Excellent results can be obtained regardless

of surgical modality (cold instruments, laser)

provided the surgical approach is well thought

out. Selection of modality is based on surgeon

preference and experience

• Laser safety precautions and closed- loop

communication during oxygen titration are

paramount when lasers are used

Case Presentation

A 3- month- old male, otherwise healthy, term- infant, was followed since his 2nd day of life for progress ively worsen-ing inspiratory stridor. By the sixth week of life, the child had developed feeding difficulties and interruption sec-ondary to respiratory difficulty with resultant poor weight gain. His physical examination was significant for inspira-tory stridor worsening with agitation. Fiber- optic flexible laryngoscopy revealed an omega- shaped epiglottis, short aryepiglottic folds, and dynamic collapse of the supra-glottis into the laryngeal inlet. The patient had contin-ued symptoms with cyanotic episodes that self- resolved, as well as poor weight gain despite an anti- reflux regimen including thickened feeds and maximal proton pump in-hibitor therapy. A modified barium swallow demonstrat-ed no evidence of aspiration. Given the progressive symp-toms and failure to thrive, the family was offered operative

104 Ambrosio · Brigger

References

1 Richter GT, Thompson DM: The surgical management of laryngomalacia. Otolar-yngol Clin North Am 2008;41:837– 864, vii.

2 Zoumalan R, Maddalozzo J, Holinger LD: Etiology of stridor in infants. Ann Otol Rhinol Laryngol 2007;116:329– 334.

3 Thompson DM: Abnormal sensorimotor integrative function of the larynx in con-genital laryngomalacia: a new theory of etiology. Laryngoscope 2007;117:1– 33.

4 Messner AH: Congenital Disorders of the Larynx. Cummings Otolaryngology: Head & Neck Surgery, ed 5. Philadel-phia, Mosby, 2010.

5 Matthews BL, Little JP, McGuirt WF, et al: Reflux in infants with laryngomala-cia: results of 24- hour double- probe pH monitoring. Otolaryngol Head Neck Surg 1999;120:860– 864.

6 Solomons NB, Prescott CA: Laryngomal-acia. A review and the surgical manage-ment for severe cases. Intl J Pediatric Otorhinolaryngol 1987;13:31– 39.

7 Schroeder JW Jr, Thakkar KH, Poznano-vic SA, Holinger LD: Aspiration follow-ing CO2 laser- assisted supraglottoplasty. Int J Pediatr Otorhinolaryngol 2008;72: 985– 990.

8 Denoyelle F, Mondain M, Gresillon N, Roger G, Chaudre F, Garabedian EN: Failures and complications of supraglot-toplasty in children. Arch Otolaryngol Head Neck Surg 2003;129:1077– 1080.

intervention. Direct laryngoscopy and bronchoscopy confirmed findings of an omega- shaped epiglottis, short aryepiglottic folds, and no evidence of a secondary air-way lesion such as subgottic stenosis or tracheobron-chomalacia. Suspension laryngoscopy was performed with a Lindholm laryngoscope following completion of the bronchoscopy, and adequate spontaneous ventila-tion anesthesia was obtained. Aryepiglottic fold division was performed bilaterally using microlaryngeal scissors.

The author judiciously removed triangular wedges of the aryepiglottic folds. The patient’s postoperative course was uneventful with immediate improvement in stridor and feeding. At the 6- week postoperative visit, the child dem-onstrated appropriate weight gain, no clinical evidence of aspiration and minimal inspiratory stridor. The parents voiced a high level of satisfaction.

Matthew T. Brigger, MD, MPH, LCDR, MC, USN

Naval Medical Center San Diego

Department of Otolaryngology, Head and Neck Surgery

34800 Bob Wilson Drive

San Diego, CA 92134 (USA)

E- Mail matthew.brigger@med.navy.mil