Supraglottoplasty in Infants Using Sinus Instruments

Introduction

Laryngomalacia is the most common cause of stridor in neonates. Holinger found laryngomalacia in 60% of children with congenital laryngeal anomalies who presented with stridor.[1] Most children with laryngomalacia resolve within 18 to 24 months of birth and require no specific treatment. Quality-of-life analysis has found that most caregivers were not substantially affected by providing care to the child with laryngomalacia.[2]

However, children with severe laryngomalacia may develop marked upper airway obstruction resulting in cor pulmonale, life-threatening apneic episodes, feeding difficulties, obstructive sleep apnea, and failure to thrive.[3] While tracheotomy has been used in complex neonates in whom laryngomalacia is associated with other anomalies or medical problems, surgical resection of supraglottic tissues – “supraglottoplasty” – has been the favored approach.

We describe a simple, safe, and effective method of supraglottoplasty, first used by the senior author (DET), using through-cutting sinus dissection forceps (Figure 1) to incise or resect a portion of the aryepiglottic fold.

Figure 1.

Straight through-cutting sinus forceps and Parsons laryngoscope used for supraglottoplasty.

Method/Surgical Procedure

Infants were diagnosed with laryngomalacia by awake fiberoptic laryngoscopy performed in the office setting. Supraglottoplasty was recommended for the unusual infant with laryngomalacia who had increased work of breathing requiring hospitalization or had failure to thrive from feeding difficulties.

Supraglottoplasty was performed under general anesthesia at the time of endoscopy to exclude synchronous airway lesions. Infants were suspended with a Benjamin-Parsons laryngoscope, and the larynx was visualized with the operating microscope or a rigid telescope. The aryepiglottic folds were palpated with and without the presence of an endotracheal tube (Figure 2a). The area of constriction, usually just anterior to the cuneiform cartilage, was grasped with the straight through-cutting sinus forceps with a 3- to 4-mm jaw length (Medtronic-Xomed, Jacksonville, Florida; Boss Instruments, Nashville, Tennessee) (Figure 2b). The tissue was slowly compressed to facilitate hemostasis, until the cut was completed and tissue removed (Figure 2c). The incision usually extends to, but not inferior to, the level of the false vocal cord. A small wedge of tissue is removed to effectively lengthen the aryepiglottic fold. Wider or deeper incision/excision can be accomplished with additional applications of the through-cutting forceps. Pledgets of cocaine or oxymetazoline can be applied for hemostasis.

Figure 2a.

Laryngomalacia in patient 1, with aryepiglottic fold exposed with the Benjamin-Parsons suspension laryngoscope while intubated.

Figure 2b.

Right aryepiglottic fold being compressed and incised with the through-cutting forceps.

Figure 2c.

Both aryepiglottic folds have had wedge-resection supraglotttoplasty.

Case Report

A 2-month-old male child, born at term by vaginal delivery, was referred to Johns Hopkins Pediatric Otolaryngology with progressive airway obstruction and inspiratory stridor first noted at 4 days of age. At evaluation, he was a well-nourished 5-kg infant with inspiratory high-pitched stridor, marked inspiratory sternal retraction, and a normal cry. Prolonged feeding time was noted in the clinic. Fiberoptic optic laryngoscopy showed inspiratory supraglottic obstruction from constricted aryepiglottic folds and anteromedial curling of the supra-arytenoid mucosa.

He was admitted to the Johns Hopkins Children's Center with increased work of breathing. He underwent supraglottoplasty by conservative excision of a small wedge of aryepiglottic fold on each side (Figures 2a-c). He was extubated shortly after surgery and was discharged after 24 hours of monitored observation with no stridor. He continues to do well without symptoms at 22 months of age.

Discussion

Laryngomalacia is usually a self-limited condition, but it can be associated with gastroesophageal reflux, neuromotor disease, and obstructive apnea.[4,5] Infants with severe laryngomalacia may require supraglottic surgery to prevent the consequences of neonatal upper airway obstruction.

Holinger described several patterns of inspiratory supraglottic collapse, one or more of which are found in each infant with laryngomalacia: inward aryepiglottic fold collapse (type 1), tubular epiglottic shape (type 2), anterior-medial collapse of the arytenoids (type 3), posterior epiglottic displacement (type 4), short aryepiglottic folds (type 5), and an acutely angled epiglottis at the petiole (type 6).

The mainstay of surgical treatment has been resection of the aryepiglottic fold.[1,3] Resection of a portion of the aryepiglottic fold has been shown to be effective,[6] but simple incision of the aryepiglottic fold improved almost 90% of children with severe laryngomalacia in one series.[7] The need to lengthen the aryepiglottic fold is highlighted by Manning and colleagues,[8] who found lower aryepiglottic fold length-glottic length ratios in children requiring surgery for laryngomalacia when compared with controls.

Supraglottoplasty has been performed with “cold” microsurgical instruments and the CO₂ laser.[9] Supraglottic stenosis and interarytenoid adhesion have been described as complications, scarring that has a much poorer prognosis than laryngomalacia itself. Kelly and Gray used unilateral supraglottoplasty as a means of reducing the potential for such complications, although staged surgery on the second side was required in 3 of their 18 patients.[10] Conservative, precise tissue division or removal seems prudent.

The advantages of using through-cutting sinus forceps to incise/excise aryepiglottic fold tissue in infants with laryngomalacia are listed in the Table. The length of conventional sinus through-cutting forceps, about 11 cm, is ideal for use with the neonatal Benjamin-Parsons laryngoscopes, particularly when compared with 22-cm microlaryngeal scissors. The procedure can be performed on both sides in a few minutes, without special equipment such as lasers, microdebriders, or laser-safe endotracheal tubes.

Table.

Supraglottoplasty Using Sinus Instruments

ADVANTAGES	DISADVANTAGES
Ideal instrument length	Not helpful for posterior epiglottic displacement
Precise excision with reduced tissue trauma	Need adjunctive resection for redundant supra-arytenoid mucosa
Can be performed with/without endotracheal tube	Thick aryepiglottic folds may be hard to cut
Rapid operative time
Instruments available in every ENT OR
Avoid cumbersome equipment and setup time

The procedure is enhanced, rather than encumbered, by the use of an endotracheal tube, providing greater safety for neonates with lung disease or severe gastroesophageal reflux who need maintained airway control. Tissue excision is precise and limited when using the through-cutting forceps. We expect this limits granulation and scarring.

The limitations of this procedure are several. Laryngomalacia that involves posterior displacement of the epiglottis (Holinger type 4) may not be completely relieved by aryepiglottic fold division, although we have rarely seen this occur in otherwise healthy infants.[11–13] The presence of marked supra-arytenoid mucosal collapse (Holinger type 1) may require resection in addition to aryepiglottic fold division.

Conclusion

Through-cutting sinus forceps can be used to rapidly and precisely incise and excise aryepiglottic folds of neonates with laryngomalacia. This technique may have technical advantages over the use of microlaryngeal instrumentation or laser.