ABSTRACT
Objective
To evaluate the feasibility, safety, and clinical outcomes of transcervical epiglottic suspension in respiratory support‐dependent infants with Type III laryngomalacia.
Methods
This retrospective case series at a single‐center tertiary children's hospital included consecutive infants with endoscopically confirmed Type III laryngomalacia who were dependent on respiratory support because of upper airway obstruction. These infants underwent transcervical epiglottic suspension between January 1, 2024, and December 31, 2025. Because all eligible infants treated during the study period were included, no a priori sample size calculation was performed. Outcomes included procedural success, operative time, suture duration, perioperative complications, liberation from respiratory support, avoidance of tracheostomy, improvement in airway obstruction, feeding recovery, and catch‐up growth.
Results
Fifteen infants were included. Median age at surgery was 58 days. Primary procedural success was achieved in 14 of 15 infants and in all infants after revision. All infants were liberated from respiratory support, and none required tracheostomy. Airway obstruction scores improved significantly after surgery (p < 0.001). Median operative time was 20 min, median blood loss was 1 mL, median suture duration was 35 days, and median time to full oral feeding was 35 days. Among 10 infants with preoperative growth impairment, eight achieved normal weight‐for‐age status at final follow‐up. Adverse events included premature suture detachment in two infants and minor cutaneous pressure injury in one infant; no severe complications occurred.
Conclusion
Transcervical epiglottic suspension was feasible and was associated with rapid liberation from respiratory support and an acceptable safety profile in high‐risk infants with Type III laryngomalacia.
Level of Evidence
4
Keywords: airway obstruction, epiglottic prolapse, infant, laryngomalacia, transcervical epiglottic suspension
1. Introduction
Type III laryngomalacia (LM), the least common subtype, is characterized by posterior epiglottic prolapse (EP) into the airway and can cause severe upper airway obstruction [1, 2]. Infants with severe Type III typically present with inspiratory stridor, respiratory retractions, apnea, and potential cyanosis, frequently accompanied by feeding dysfunction and failure to thrive, posing a significant risk of morbidity [3, 4]. Without timely definitive intervention, these infants often require prolonged ventilatory support and extended hospitalization, amplifying the family burden without precluding the potential need for eventual surgery [5, 6].
Surgical management for severe EP ranges from endoscopic epiglottopexy—performed via laser‐ or coblation‐assisted demucosalization followed by suture fixation—to selective partial epiglottidectomy [7, 8, 9, 10]. However, these technically demanding procedures carry risks of mucosal injury, and treatment failure may necessitate reoperation or ultimately tracheostomy [11, 12]. Consequently, there is a need for more predictable surgical strategies. Addressing this, transcervical external‐puncture epiglottopexy has demonstrated high efficacy since 2019, and Kanotra et al. later reported a 95% success rate [2, 13]. Nevertheless, such techniques typically rely on a combined trans‐lingual and trans‐cartilaginous needle passage, a maneuver that limits precise control. Moreover, current evidence is derived largely from older children, leaving a gap regarding ventilator‐dependent infants with low body weight.
We describe herein a modified technique: transcervical epiglottic suspension (TES). To our knowledge, this represents the first description of this approach in infants with severe Type III LM. We hypothesized that TES would provide controlled anterior support of the prolapsing epiglottis, thereby improving supraglottic airway patency while avoiding excessive mucosal disruption or rigid tongue‐base fixation. We further hypothesized that, in respiratory support‐dependent infants with severe Type III LM, TES would be feasible and safe and would be associated with sustained liberation from respiratory support, avoidance of tracheostomy, improved feeding, and catch‐up growth. Therefore, this study aimed to describe the TES technique and evaluate its feasibility, safety, and clinical outcomes in this high‐risk infant population.
2. Materials and Methods
2.1. Study Design and Ethics
This study was approved by the Institutional Review Board of Children's Hospital Affiliated to Zhengzhou University (approval No. 2026‐IITGC‐001‐001). The institutional review board waived the requirement for written informed consent because of the retrospective design and use of fully deidentified data. We identified eligible infants with severe LM treated in the Department of Otolaryngology–Head and Neck Surgery from January 1, 2024 to December 31, 2025. Given the retrospective nature of this consecutive case series, an a priori sample size calculation was not performed.
2.2. Patient Selection and Diagnostic Criteria
Consecutive infants were eligible if they met all of the following criteria: (1) age younger than 1 year at surgery; (2) endoscopically confirmed Type III LM, defined as dynamic posterior epiglottic prolapse into the laryngeal inlet during inspiration; (3) severe upper airway obstruction requiring invasive mechanical ventilation or noninvasive respiratory support; and (4) TES performed during the study period [14]. Patients were excluded if they had synchronous airway lesions sufficient to independently explain the obstruction, including severe micrognathia, bilateral vocal fold paralysis, subglottic stenosis, or severe tracheomalacia. Cardiac and gastrointestinal comorbidities were not exclusion criteria unless they independently explained the need for respiratory support.
Fifteen infants met the inclusion criteria. Baseline demographic and clinical data were extracted (Table 1), specifically age, sex, weight, LM classification (Olney system), and EP severity (Kanotra grades) [1, 2]. Preoperative respiratory symptom severity was stratified as mild, moderate, or severe.
TABLE 1.
Baseline characteristics of infants with Type III laryngomalacia.
| Characteristics | Total (N = 15) a |
|---|---|
| Age at surgery, median (range), d | 58 (10–118) |
| Sex | |
| Male | 8 (53.3) |
| Female | 7 (46.7) |
| Preoperative respiratory support | |
| Noninvasive ventilation (CPAP/BiPAP) | 12 (80.0) |
| Invasive mechanical ventilation | 3 (20.0) |
| Preoperative symptom severity b | |
| Mild | 5 (33.3) |
| Moderate | 7 (46.7) |
| Severe | 3 (20.0) |
| Anthropometric data | |
| Weight at surgery, median (range), kg | 3.62 (2.28–4.40) |
| WAZ, median (IQR) | −3.50 (−4.19 to −1.62) |
| Underweight (WAZ < −2) | 10 (66.7) |
| Severe underweight (WAZ < −3) | 9 (60.0) |
Note: All infants had dominant Olney Type III laryngomalacia (epiglottic prolapse; Kanotra Grade 4) with varying degrees of coexisting Type I or II features. For Patient 8, the initial TES was counted as an early procedural failure requiring revision; anthropometric baseline values used for growth‐trajectory analyses were referenced to the revision admission.
Abbreviations: BiPAP, bilevel positive airway pressure; CPAP, continuous positive airway pressure; IQR, interquartile range; WAZ, weight‐for‐age z score.
Data are no. (%) unless otherwise indicated.
Severity grading: mild (stridor), moderate (dyspnea or retractions), and severe (cyanosis).
2.3. Surgical Technique
All procedures were performed under general anesthesia by the same pediatric otolaryngology team. All infants underwent TES after endoscopic supraglottoplasty was performed to address coexisting Type I or II features. Therefore, the reported outcomes reflect the combined management strategy, with TES specifically targeting posterior epiglottic prolapse. A 4–0 polypropylene (Prolene) suture was fashioned into a U‐shaped suspension stitch via trans‐epiglottic passage in a lingual–laryngeal–lingual sequence (Figure 1A). Under endoscopic guidance, a 21‐gauge needle preloaded with a 4–0 polypropylene Ω‐loop was introduced percutaneously from the suprahyoid midline through the tongue base to the vallecula (Figure 1B) to exteriorize the suspension suture (Figure 1C). Tension was adjusted endoscopically to optimize inlet patency while preventing hyper‐anteriorization, and the suture was tied over an external silicone tube bolster cushioned by a basal pad (Figure 1D). Final laryngoscopy confirmed airway patency prior to transfer to the intensive care unit. The operative workflow is demonstrated in Video 1.
FIGURE 1.
Key steps of transcervical epiglottic suspension (TES). (A) Trans‐epiglottic suture placement. (B) Endoscopic Ω‐loop needle advancement. (C) Suture exteriorization. (D) Tensioning and fixation over an external bolster. Endotracheal tube omitted.
2.4. Postoperative Management and Follow‐Up
Postoperatively, patients remained intubated and sedated until stable for extubation; noninvasive support was titrated as indicated. None of the 15 infants underwent formal swallowing assessment with videofluoroscopic swallow study (VFSS) or fiberoptic endoscopic evaluation of swallowing (FEES). Aspiration risk was assessed clinically based on overt choking during feeding and pulmonary status. All infants received prophylactic nasogastric (NG) feeding before and after TES, followed by a stepwise transition to oral feeding after endoscopic confirmation of airway stability and demonstration of clinical feeding tolerance. Serial laryngoscopy (Weeks 1, 3, 6) monitored epiglottic position. Dynamic laryngoscopic examinations were routinely video‐recorded at each follow‐up time point, including the examination performed at suture removal. Sutures were removed upon confirmation of a healed glossoepiglottic adhesion [2]. Follow‐up continued for at least 3 months or until the study cutoff (December 31, 2025). Longitudinal weights recorded at Postoperative week 1, suture removal, and final follow‐up (December 31, 2025) were standardized to weight‐for‐age z scores (WAZ) using World Health Organization (WHO) Child Growth Standards (sex‐specific LMS method). Underweight (WAZ < −2) and severe underweight (WAZ < −3) were classified according to WHO criteria [15].
2.5. Outcome Measures
Outcomes were prespecified as feasibility, safety, and clinical effectiveness measures. Feasibility outcomes included successful completion of transcervical epiglottic suspension (TES), operative time for suspension, and suture fixation duration. Primary procedural success was defined as stable anterior epiglottic suspension after the initial TES without early suture detachment or recurrent epiglottic prolapse requiring revision. Overall procedural success included success after revision TES when performed. Safety outcomes included intraoperative hemorrhage, airway or laryngeal injury, nerve injury, postoperative pneumonia, infection, cervical pressure injury, premature suture detachment, revision surgery, reintubation, tracheostomy, and other perioperative complications [16, 17]. Clinical outcomes included sustained liberation from invasive or noninvasive respiratory support, avoidance of tracheostomy, improvement in airway obstruction severity, time to full oral feeding, hospital length of stay, and longitudinal change in weight‐for‐age z score (WAZ). Respiratory liberation was defined as independence from invasive and noninvasive respiratory support for at least 7 consecutive days [18, 19]. Airway obstruction severity was scored at baseline, extubation, and discharge on a 4‐point scale: 0, none; 1, mild stridor; 2, dyspnea or retractions; and 3, cyanosis [20]. Preoperative pneumonia was identified on chest computed tomography (CT). Postoperative improvement was defined by reduced pulmonary opacities or infiltrates on chest radiography. New pneumonia required a documented clinical diagnosis supported by imaging. For longitudinal feeding and growth outcomes, time points were indexed to the definitive TES procedure. In infants requiring revision, the initial TES was counted as primary procedural failure, whereas feeding and growth time points were referenced to the revision procedure to standardize follow‐up intervals [21].
2.6. Statistical Analysis
Data are expressed as median (interquartile range [IQR]), median (range), or number (%) as appropriate. Nonparametric analyses used the Friedman test for longitudinal trends and the Wilcoxon signed‐rank test for paired pre–post comparisons. Significance was defined as two‐sided p < 0.05. A sensitivity analysis was performed after excluding the two infants who underwent concurrent major non‐airway procedures, with recalculation of time to liberation from respiratory support, postoperative hospital length of stay, and time to full oral feeding. Visualization included alluvial diagrams mapping symptom transitions and box plots overlaid with individual trajectories for growth (reference lines: −2 and −3 standard deviations [SD]). Analyses were performed using R version 4.5.2.
3. Results
3.1. Baseline Characteristics
Fifteen infants (eight boys and seven girls) underwent TES for severe Type III LM (Table 1). None of the 15 infants had undergone supraglottoplasty or any other airway surgery before TES. At the time of surgery, the median age was 58 days (range, 10–118) and the median weight was 3.62 kg (range, 2.28–4.40). All patients exhibited posterior EP, consistently associated with variable degrees of Type I or II features (arytenoid mucosal redundancy or shortened aryepiglottic folds). Preoperative obstruction severity was graded as moderate in seven infants (47%) and severe in 3 (20%). The remaining 5 (33%), while lacking retractions, warranted intervention due to resting stridor complicated by pronounced respiratory acidosis. All infants required preoperative respiratory support. Twelve infants (80%) were managed with noninvasive ventilation, and 3 (20%) required invasive mechanical ventilation. Baseline nutritional compromise was substantial (median WAZ, −3.50 [IQR, −4.19 to −1.62]): 10 infants (66.7%) were classified as underweight (WAZ < −2), including 9 (60.0%) who were severely underweight (WAZ < −3).
3.2. Perioperative Feasibility and Safety
All 15 infants underwent TES without intraoperative conversion or procedural abandonment. Primary stable epiglottic suspension was achieved in 14 of 15 cases (93%). In one case (Patient 8), initial postoperative laryngoscopy revealed premature suture detachment. Despite this, improved epiglottic stability and marked symptomatic improvement permitted discharge after conservative management. Four days later, an acute upper respiratory infection precipitated recurrent stridor and retractions. Laryngoscopy confirmed recurrence of significant EP, necessitating readmission and noninvasive ventilation. Following successful revision TES, the patient achieved extubation within 24 h and required no further respiratory support, resulting in a final success rate of 100%. For longitudinal analyses, time points for Patient 8 were anchored to the revision procedure, with the initial suture detachment categorized as an early procedural failure.
Concurrent procedures were performed in two infants—one undergoing thoracoscopic repair of congenital heart defects and the other undergoing laparoscopic biliary exploration—without TES‐related intraoperative complications. The median operative time for suspension was 20 min (range, 15–30; Table 2). Intraoperative blood loss was negligible (median, 1 mL). The maximum loss (10 mL) occurred in the patient undergoing concurrent cardiac surgery, whereas blood loss in the remaining cohort was limited to 1–2 mL. No anesthetic or surgical complications occurred.
TABLE 2.
Operative, respiratory, feeding, and safety outcomes (N = 15).
| Outcome measures | Results |
|---|---|
| Primary efficacy endpoints | |
| Liberation from respiratory support, no. (%) | 15 (100) |
| Time to liberation from respiratory support, median (range), d | 1 (0–2) |
| Respiratory symptom scores (0–3) | |
| Preoperative, median (range) | 2 (1–3) |
| Postoperative (at extubation), median (range) | 0 (0–1) |
| Discharge, median (range) | 0 (0–0) |
| p a | < 0.001 |
| Surgical feasibility and safety | |
| Operative time for suspension, median (range), min | 20 (15–30) |
| Intraoperative blood loss, median (range), mL | 1 (1–10) |
| Adverse events, no. (%) b | 3 (20.0) |
| Suture fixation duration, median (range), d | 35 (7–44) |
| Postoperative recovery | |
| Return to full oral feeding, median (range), d | 35 (5–44) |
| Hospital length of stay, median (range), d | 13 (5–32) |
Calculated using the Wilcoxon signed‐rank test comparing preoperative scores with scores at extubation.
Adverse events included two cases of premature suture detachment, one of which required revision TES, and one case of minor cutaneous pressure injury; no severe complications occurred.
Postoperative morbidity was minimal, with no severe complications such as iatrogenic airway trauma, vocal fold injury, or neural injury. All 15 infants had pneumonia confirmed on preoperative chest CT. Routine postoperative chest radiographs demonstrated interval improvement in pulmonary opacities or infiltrates in all infants, and no new clinically diagnosed episode of pneumonia occurred during hospitalization. Adverse events were limited to two instances of premature suture detachment (Patient 8 and a second case detailed below) and 1 localized superficial pressure injury with granulation tissue at the cervical anchor site. There was no evidence of infection. The lesion resolved completely after conservative pressure relief and local wound care, with no residual scarring or other sequelae. Critically, no patient required reintubation or tracheostomy. All 15 infants were initially weaned from respiratory support by Postoperative day 2 (median, 1 day; range, 0–2 days), and all maintained independence from invasive or noninvasive support for at least 7 consecutive days, meeting the predefined criterion for respiratory liberation. Specifically, liberation occurred on the day of surgery (n = 7), Postoperative day 1 (n = 5), or day 2 (n = 3). All patients were discharged breathing independent of respiratory support, with a median hospital length of stay of 13 days (range, 5–32 days).
3.3. Respiratory Outcomes
Serial laryngoscopy demonstrated progressive airway patency (Figure 2). Preoperatively, all infants had a retroflexed epiglottis causing near‐total airway obstruction, consistently associated with variable Type I and II characteristics (Figure 2A). At Postoperative week 1, the epiglottis remained suspended in an anterosuperior position, preventing inspiratory collapse while preserving normal mobility, aside from mild marginal edema and thin fibrinous exudate at the arytenoid region (Figure 2B). By Week 3, the epiglottis maintained a stable configuration and a patent airway even during vigorous inspiration, while swallowing dynamics were preserved without clinical aspiration (Figure 2C). Following suture removal, minimal granulation tissue was noted at the glossoepiglottic interface, indicating that the epiglottis was not rigidly fixed; rather, patency was maintained by improved muscle tone and favorable airway geometry (Figure 2D). Representative serial dynamic laryngoscopic recordings from the same infant shown in Figure 2 are provided in Video 2. The recordings correspond to the Preoperative, Postoperative week 1, postoperative week 3, and suture‐removal examinations and demonstrate maintained airway patency during spontaneous respiration and vigorous inspiration. Notably, in Patient 4, despite premature suture detachment at Day 7, resolution of stridor was sustained, with follow‐up laryngoscopy at 3 weeks confirming a stable epiglottis without recurrence. For the remainder of the cohort (excluding this episode and the initial procedure for Patient 8), elective suture removal was performed during Postoperative weeks 3 (n = 1), 4 (n = 1), 5 (n = 8), and 6 (n = 4).
FIGURE 2.
Serial endoscopic views before and after transcervical epiglottic suspension. (A) Preoperative severe Type III laryngomalacia. (B) Postoperative week 1. (C) Postoperative week 3 showing sustained patency. (D) Week 6 at suture removal. The images were captured from the serial dynamic laryngoscopic recordings provided in Video 2.
At extubation, 13 of 15 patients (87%) had complete resolution of stridor, contrasting with preoperative findings of mild (n = 5), moderate (n = 7), or severe obstruction with cyanosis (n = 3). The remaining two infants had mild residual stridor, but all patients were symptom‐free by discharge (Figure 3). Quantitatively, this improvement in respiratory scores was statistically significant (p < 0.001, Wilcoxon signed‐rank test; Table 2).
FIGURE 3.
Respiratory symptom severity over time. Scores range from 0 (none) to 3 (severe). Stream width represents patient count. All infants achieved complete symptom resolution by hospital discharge.
3.4. Feeding Recovery and Growth
All infants received prophylactic NG feeding during the initial recovery phase. The median time to achieve full oral feeding was 35 days (range, 5–44 days; Table 2), but varied notably based on preoperative growth status. The five infants with normal preoperative growth achieved early weaning from NG support (within 3 weeks) following endoscopic confirmation of stability. Among these, tube withdrawal occurred following the first laryngoscopy at Days 5 (n = 1) and 8 (n = 3), and at Week 3 during the second laryngoscopy and simultaneous suture removal (n = 1). In contrast, the 10 infants presenting with baseline growth impairment (underweight) required 4–6 weeks of NG support before achieving safe oral intake. In this cohort, the transition to full oral feeding typically coincided with suture removal, corresponding to a median fixation duration of 35 days (range, 7–44 days). The median follow‐up duration was 398 days (range, 69–680 days), with 13 of 15 infants followed for more than 3 months. All infants ultimately achieved full oral feeding.
Complete growth data were obtained for all 15 infants (Table S1). From a baseline median WAZ of −3.50 (IQR, −4.19 to −1.62), nutritional status remained stable at Postoperative week 1 (median WAZ, −3.52 [IQR, −4.33 to −1.84]), despite universal absolute weight gain (Figure 4A). By the time of suture removal, however, the median WAZ shifted upward to −2.01 (IQR, −3.78 to −1.39), concurrent with a marked reduction in the severity of growth impairment (underweight, n = 9; severe underweight, n = 5). Improvement continued through the final follow‐up (median WAZ, −0.93 [IQR, −1.57 to 0.05]), at which point severe underweight had resolved in all cases (n = 0), and only two infants remained classified as underweight (Figure 4B).
FIGURE 4.
Weight recovery after transcervical epiglottic suspension. (A) Individual weight trajectories. (B) Longitudinal weight‐for‐age z scores at baseline, Week 1, suture removal, and final follow‐up. For Patient 8, growth time points were indexed to the revision TES procedure.
3.5. Sensitivity Analysis
A sensitivity analysis was performed after excluding the two infants who underwent concurrent non‐airway procedures. In the remaining 13 infants, the median time to liberation from respiratory support was 1 day (range, 0–2 days), the median postoperative hospital length of stay was 13 days (range, 5–32 days), and the median time to full oral feeding was 35 days (range, 8–44 days). The corresponding values in the full cohort were 1 day (range, 0–2 days), 13 days (range, 5–32 days), and 35 days (range, 5–44 days), respectively. Thus, exclusion of these two infants did not alter the median estimate for any of the three recovery outcomes.
4. Discussion
The Olney system classifies LM based on anatomical defects observed during endoscopy: prolapse of arytenoid mucosa (Type I), foreshortened aryepiglottic folds (Type II), and posterior epiglottic displacement (Type III) [1]. In severe cases, these features frequently coexist. Type III LM accounts for 5.4%–13% of cases [1, 4, 22]. Approximately 53%–60% of patients present with mixed variants, underscoring that EP frequently coexists with Type I or II features, consistent with a multilevel pattern of obstruction [4, 22]. Supraglottoplasty is the standard treatment for severe LM [23, 24]. However, it is often insufficient for Type III cases [3]. The clinical relevance of this series lies in a narrowly defined but high‐risk population: infants with severe Type III LM who are dependent on respiratory support and in whom prolonged noninvasive ventilation, repeated extubation failure, or tracheostomy may otherwise be considered. In this setting, TES provides a reproducible approach that directly addresses epiglottic prolapse while preserving the possibility of rapid postoperative respiratory weaning and staged nutritional recovery.
For severe Type III LM, epiglottopexy is often a necessary intervention [2, 8, 9, 10, 13]. Early management relied on laser‐induced fibrosis to reposition the epiglottis, but outcomes depended on unpredictable scar formation [8]. To provide secure fixation, Sandu et al. [9] introduced an endoscopic technique using the Lichtenberger needle carrier; however, this requires specialized instrumentation. Subsequently, Hazkani et al. [10] described endoscopic suturing using standard instruments but noted that restricted laryngeal exposure often limited the procedure, rendering deep tongue‐base fixation technically challenging. Consequently, transcervical “outside‐in” approaches were developed [2, 13]. While existing methods have varying strengths and limitations, given that severe prolapse results in persistent obstruction and prolonged ventilation, our objective was not to assert superiority over other techniques, but to evaluate the feasibility, safety, and initial clinical outcomes of TES for these high‐risk infants.
In our series, all 15 infants (median age, 58 days) were liberated from respiratory support after surgery, achieving a 93% primary success rate that reached 100% following a single revision. Clinical resolution was rapid, with 87% of infants stridor‐free by extubation and all asymptomatic by discharge. The observed airway improvement was maintained during the available follow‐up and was accompanied by progressive catch‐up growth. Collectively, these findings support the feasibility of TES and suggest favorable early clinical outcomes in this high‐risk population. No severe TES‐related complications were observed in this cohort. The median operative time for suspension was 20 min with minimal blood loss. No airway trauma, nerve injury, or postoperative pneumonia occurred. Our results align with those of Kanotra et al. [2], who reported 95% success and no intraoperative complications via a transcervical approach in 18 children (mean age, 4 years). Our findings suggest that external epiglottic suspension is technically feasible even in very young, low‐weight infants, although direct comparison with previously reported cohorts is limited by differences in patient characteristics and study design. TES was technically completed without TES‐related intraoperative complications in the two infants who underwent concurrent non‐airway procedures. Sensitivity analysis excluding these infants did not materially affect the median estimates of respiratory liberation, postoperative hospital stay, or time to full oral feeding. In our series, two infants experienced premature suture detachment (on Postoperative days 7 and 10, respectively), and one developed a minor cutaneous pressure injury; all were managed conservatively or with revision, resulting in no long‐term sequelae. Historically, a subset of infants with severe EP required prolonged ventilation or tracheostomy when less invasive measures failed [11, 12]. The avoidance of tracheostomy in our cohort is encouraging and suggests that TES may represent a potential tracheostomy‐sparing option for selected infants with severe Type III LM.
Conceptually, TES resembles epiglottopexy but differs in mechanics. Unlike the continuous puncture trajectory from the neck through the tongue base to the epiglottis used in previous methods, our technique involves distinct steps: A 4‐0 Prolene suture is passed trans‐epiglottically in a lingual–laryngeal–lingual sequence and externalized using a percutaneous needle loop from the suprahyoid midline. By integrating external puncture with endoscopic suturing, our technique allows for precise localization and adjustment. Rather than suturing the epiglottis to a rigid anchor like the tongue base, TES functions as a sling, suspending the epiglottis anteriorly to widen the airway. We favor the term “epiglottic suspension” over “epiglottopexy,” as the technique relies on tension‐based elevation rather than static fixation, enabling us to fine‐tune epiglottic displacement to secure airway patency without clinically evident deterioration in swallowing.
Severe LM is frequently associated with feeding difficulties and aspiration risk. Bredun et al. [3] observed feeding difficulties in 100% of infants with Type III LM (vs. 83% in Type II) and noted an inverse relationship between disease severity and weight gain. Furthermore, research indicates that more than 40% of symptomatic infants with LM demonstrate aspiration on videofluoroscopic swallow studies, with nearly all (98%) aspirating silently without obvious choking symptoms [25]. Silent aspiration significantly aggravates the respiratory compromise in these infants [26]. Consistent with these reports, the majority of infants in our series presented with preoperative feeding difficulties. All infants received NG feeding for nutritional support and airway protection prior to surgery. Despite this precaution, preoperative chest CT scans showed varying degrees of pneumonia in all infants, a finding that likely contributed to the severity of their respiratory symptoms. Recognizing the potential risk of aspiration with the epiglottis suspended anteriorly, we maintained NG feeding postoperatively for all patients. Routine postoperative chest radiographs showed interval improvement in pulmonary opacities or infiltrates, with no new clinically diagnosed pneumonia during follow‐up, indicating favorable postoperative pulmonary outcomes. As postoperative edema resolved and the epiglottis stabilized, oral feeding was reintroduced in a stepwise manner with close monitoring. The median time to achieve full oral feeding was 35 days (range, 5–44 days). Our data suggest that infants without growth impairment may be candidates for early tube withdrawal following endoscopic verification of structural stability, whereas those with preoperative failure to thrive required 4–6 weeks of NG feeding for nutritional recovery—a duration that coincided with suture removal. Prolonged NG feeding, particularly for growth‐impaired infants, served as a safety precaution rather than indicating surgical failure. This recovery period may provide additional time for feeding adaptation and nutritional recovery in infants with severe preoperative airway obstruction, consistent with the known association between severe LM and feeding inefficiency [3, 25, 26].
Furthermore, postoperative follow‐up demonstrated substantial catch‐up growth. At baseline, 10 infants (67%) were underweight (WAZ < −2), including 9 (60%) with severe underweight (WAZ < −3). Postoperatively, WAZ improved steadily: the median WAZ increased from −3.50 to −2.01 at the time of suture removal and reached −0.93 by the final follow‐up. Ultimately, 8 of the 10 growth‐impaired infants achieved a normal weight, and severe underweight resolved in all cases. These findings suggest that relief of airway obstruction, together with structured postoperative nutritional support, may contribute to catch‐up growth in this high‐risk population. They are consistent with previous studies showing that severe LM in infancy is often associated with growth impairment, making early treatment important not only for airway patency but also for overall development [3, 24, 27, 28, 29].
Finally, regarding the duration of fixation, sutures were maintained according to protocol. The median duration of fixation was 35 days (range, 7–44 days). Suture removal was performed transcervically without anesthesia; the procedure was simple and safe. Excluding the two cases of premature detachment, our experience suggests that retaining the suture for approximately 3–6 weeks, with removal guided by endoscopic confirmation of epiglottic stability, may be a reasonable approach.
Although the available follow‐up was clinically reassuring, the long‐term functional consequences of glossoepiglottic adhesion remain uncertain in growing infants. In particular, changes in epiglottic mobility could theoretically affect swallowing, airway protection, cough efficiency, or phonation as the larynx develops. No clinically evident deterioration in swallowing was observed in this cohort, and all infants ultimately achieved full oral feeding. However, these functional domains were not evaluated using standardized instrumental or prospective assessments, and subtle late effects cannot be excluded.
This study has several limitations. First, it was a retrospective single‐center case series with a small sample size, reflecting the rarity of respiratory support‐dependent Type III LM in infants. Second, the absence of a control group limits causal inference, and the observed clinical improvements should be interpreted as associations rather than definitive evidence of superiority over existing techniques. Third, TES was performed with supraglottoplasty when coexisting Type I or II features were present; therefore, the independent contribution of TES cannot be fully isolated in all patients. Fourth, although all infants ultimately achieved full oral feeding without clinically evident deterioration in swallowing after TES, subtle changes in swallowing mechanics and silent aspiration could not be objectively assessed because no infant underwent VFSS or FEES. Finally, follow‐up duration varied, and phonation, cough efficiency, late dysphagia, and long‐term epiglottic mobility were not assessed using a standardized prospective protocol. Longer multicenter follow‐up with objective functional assessment is needed to confirm the durability and long‐term safety of TES.
5. Conclusions
In this consecutive case series of respiratory support‐dependent infants with severe Type III LM, TES was feasible and was associated with rapid liberation from respiratory support, avoidance of tracheostomy, and progressive feeding and growth recovery. These preliminary findings suggest that TES may represent a potentially useful tracheostomy‐sparing option for this high‐risk population, while underscoring the need for larger prospective multicenter studies to confirm durability, safety, and comparative effectiveness.
Funding
This work was supported by the Henan Provincial Key Research and Development Program (251111313700) titled “Key Technologies for Artificial Intelligence–Enabled Precision Early Prevention and Control of Pediatric Obstructive Sleep Apnea and Regional Application Demonstration.” The funder had no role in the design and conduct of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.
Disclosure
Generative artificial intelligence tools were used only for language editing, grammar refinement, and formatting assistance. No artificial intelligence tool was used to generate clinical data, perform statistical analyses, create primary scientific conclusions, or replace author judgment. All content was reviewed, edited, and approved by the authors, who take full responsibility for the submitted manuscript.
Ethics Statement
This study was approved by the Institutional Review Board of Children's Hospital Affiliated to Zhengzhou University (approval No. 2026‐IITGC‐001‐001). The requirement for written informed consent was waived by the institutional review board because of the retrospective design and the use of fully deidentified data. Written informed consent for publication of the deidentified Supplementary videos was obtained from the respective infants' legal guardians.
Conflicts of Interest
The authors declare no conflicts of interest.
Supporting information
Table S1: Postoperative growth outcomes (N = 15). This table summarizes postoperative age, weight, weight‐for‐age z score, and the proportions of infants with underweight and severe underweight at Postoperative week 1, suture removal, and final follow‐up.
Video 1. Transcervical epiglottic suspension for severe Type III laryngomalacia. This video demonstrates the key operative steps of transcervical epiglottic suspension, including trans‐epiglottic suture placement, percutaneous Ω‐loop needle advancement, suture exteriorization, and external tensioning over a bolster.
Video 2. Dynamic airway changes before and after transcervical epiglottic suspension. This video presents serial dynamic laryngoscopic examinations from the same infant shown in Figure 2. The recordings correspond to the preoperative examination, Postoperative week 1, Postoperative week 3, and the examination at suture removal. The video demonstrates the postoperative position and mobility of the epiglottis and maintenance of airway patency during spontaneous respiration and vigorous inspiration.
Acknowledgments
The authors thank all clinical staff in the Department of Otolaryngology–Head and Neck Surgery and the pediatric intensive care team for their support in the perioperative management and follow‐up of the infants included in this study.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Table S1: Postoperative growth outcomes (N = 15). This table summarizes postoperative age, weight, weight‐for‐age z score, and the proportions of infants with underweight and severe underweight at Postoperative week 1, suture removal, and final follow‐up.
Video 1. Transcervical epiglottic suspension for severe Type III laryngomalacia. This video demonstrates the key operative steps of transcervical epiglottic suspension, including trans‐epiglottic suture placement, percutaneous Ω‐loop needle advancement, suture exteriorization, and external tensioning over a bolster.
Video 2. Dynamic airway changes before and after transcervical epiglottic suspension. This video presents serial dynamic laryngoscopic examinations from the same infant shown in Figure 2. The recordings correspond to the preoperative examination, Postoperative week 1, Postoperative week 3, and the examination at suture removal. The video demonstrates the postoperative position and mobility of the epiglottis and maintenance of airway patency during spontaneous respiration and vigorous inspiration.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.