Flexible fiberoptic in office evaluation: severe laryngomalacia with an omega-shaped epiglottis, foreshortened aryepiglottic folds, and redundant arytenoid tissue. The glottis is not visualized during inspiration (a) or expiration (b)
Differential Diagnosis
Differential diagnosis for stridor in an infant includes infectious etiologies such as laryngotracheobronchitis (croup) or supraglottitis, congenital pharyngeal or laryngeal mass, congenital subglottic stenosis, tracheomalacia, bronchomalacia, retrognathia, airway hemangioma, supraglottic or hypopharyngeal mucous retention cysts, or unilateral or bilateral congenital vocal fold immobility.
Management
If the infant presents with mild or moderate laryngomalacia as previously defined, then conservative management with acid suppression and upright feeding positioning with a raised head of bed position may be trialed. Caregivers and primary care physicians should continue to monitor for signs of apnea, failure to thrive, or frequent coughing or choking with feeds. The patient should be reevaluated by a pediatric otolaryngologist if symptoms worsen.
If symptoms are within the severe category, surgical intervention should be strongly considered. Previously, tracheostomy had been the mainstay of treatment for severe symptoms. Tracheostomy may still be necessary in some cases. However, endoscopic supraglottoplasty has largely become the standard of care [4, 25].
Operative Approach: Supraglottoplasty
Indications
Surgical correction of laryngomalacia with supraglottoplasty is indicated in any patient who has been diagnosed with laryngomalacia at any of the three previously described anatomic subsites of the supraglottis and who has severe symptoms of laryngomalacia.
Key Aspects of the Consent Process
Informed consent should be obtained from caregivers after discussion of all risks, benefits, and alternatives to the procedure. The risks of the surgery may involve damage to surrounding structures such as lips, gums, tongue, and dentition. Furthermore, operating on the airway causes edema in the postoperative period, which may temporarily worsen respiratory symptoms. For this reason, patients are admitted for overnight observation and in some cases may require endotracheal tube placement or very rarely, tracheostomy. Laryngeal stenosis may result from scarring of opposing freshly cut mucosal surfaces. In some cases, this may require reoperation. Swallow function may either transiently or permanently worsen, especially with manipulation of the epiglottis [26].
Equipment
An infant Benjamin Lindholm laryngoscope is used for exposure. One port is connected to a light source and the other port is used for insufflation. The laryngoscope is connected to a Lewy arm and suspended using a Mayo stand. An operating microscope is needed as well as a full set of pediatric microlaryngeal instruments. If the laryngomalacia requires epiglottopexy, then a laryngeal needle driver and knot pusher are necessary. The most commonly used instruments are a microlaryngeal scissors and either a three or five laryngeal suction.
Drug-Induced Sleep Endoscopy
Steps
- 1.
Patient positioning . Anesthesia is maintained with total intravenous anesthesia (TIVA) with insufflation, spontaneous ventilation, and oxygenation. With this technique, the supraglottic structures are easily accessible for the surgeon, and the patient is adequately ventilated and oxygenated. The patient is positioned in a sniffing position with the head slightly flexed and the body extended at the atlanto-occipital joint. Moistened gauze is used to protect the gingiva in the edentulous infant or small child. A mouthguard may be used if the size of the mouth is adequate. Care must be taken to not rock the laryngoscope back while gaining exposure as this may place excessive pressure on alveolar ridge or the dentition and dislodge teeth.
- 2.
Exposure and suspension . The mouth is opened using a scissor technique with one finger placed on the posterior maxilla and the thumb placed on the posterior mandible. Next, the tongue is swept off to the left, and the Benjamin Lindholm is inserted into the right lingual gutter and advanced into the valleculae. The laryngoscope is pulled up and forward to expose the supraglottis and glottis and then suspended using the Lewy arm and Mayo stand (Fig. 26.2).
- 3.
Release of aryepiglottic folds . We perform supraglottoplasty with cold steel microlaryngeal instruments. The aryepiglottic folds are visualized and are operated on if foreshortened and previously identified to be an issue on dynamic flexible laryngoscopy exam. An internal branch of the superior laryngeal nerve is identified just lateral to the aryepiglottic folds, and care is taken not to injure the nerve. A Bouchayer forcep is used to gently grasp the posterior aspect of the aryepiglottic fold and provide gentle countertraction in the posterior direction (Fig. 26.3a). This places the aryepiglottic fold on gentle tension . Next, microlaryngeal scissors are used to create a 2 mm releasing incision just anterior to the Bouchayer forcep (Fig. 26.3b). After this cut, the aryepiglottic fold and epiglottis pulls anteriorly, toward the vallecula. This is repeated on the other side (Fig. 26.3c).
- 4.
Trimming of excess arytenoid mucosa . The arytenoid mucosa is trimmed if it was previously visualized creating a ball-valve effect in the glottis on dynamic flexible fiberoptic laryngeal exam. A Bouchayer forcep is used to gently grasp the superficial aspect of the mucosa overlying the arytenoid complex (Fig. 26.3d). Care is taken to avoid mucosal injury or manipulation of the interarytenoid space in order to prevent scarring and laryngeal stenosis. Then, right- or left-facing microlaryngeal scissors are used to trim excessive epithelium from the superior surface of the corniculate process (Fig. 26.3e). A deep layer of mucosa should be preserved to prevent exposed cartilage (Fig. 26.3f).
- 5.
Epiglottopexy. Epiglottopexy is performed if the epiglottis was retro-positioned and blocking the glottis during dynamic laryngeal exam. This is usually performed in conjunction with release of the aryepiglottic fold to promote further migration of the epiglottis anteriorly. However, it may be performed on its own in the absence of foreshortened aryepiglottic folds. The mucosal surface of the lingual side of the epiglottis and the mucosal surface of the valleculae must be freshened in order to promote fusion of the base of the two structures. A CO2 laser is brought into the field and used to create a raw surface of the aforementioned epithelial surfaces. Laser safety materials including skin and eye protectants with moist towels and moist telfas over the eyes are used on the patient. All staff and observers must wear laser safety eyewear. FiO2 should be lowered to <30% to reduce fire risk [27, 28]. Care should be taken to not ablate or create a deep cut through the epiglottis. Next, 3–5 vicryl sutures on an appropriately sized, curved needle are placed from the mucosa of the lingual aspect of the epiglottis to the tongue base/vallecula. Stitches are placed using a microlaryngeal needle driver, and knots are tied down using a laryngeal knot pusher. The purpose of the sutures is to create contact between the two newly exposed epithelial surfaces to promote permanent fusion.
- 6.
Hemostasis. If necessary, hemostasis is achieved using a cotton ball or 0.5″ by 0.5″ pledget soaked in oxymetazoline. Epinephrine-soaked pledgets may also be used.
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