To Stitch or Not to Stitch: Laryngeal cleft type 1
Submitted by Mark on Sat, 04/01/2017 - 23:46

Study about Laryngeal cleft type 1 and whether or not to perform a repair with stitches.
Objectives
- Review anatomy of laryngeal clefts
- Current methods of repair of Type I Laryngeal clefts
- Benefits
- Drawbacks
- Review new techniques in endoscopic laryngeal repair
- Benefits
- Drawbacks
History of Laryngeal Clefts
- Rare congenital anomaly
- Congenital laryngeal anomaly occurs in 1 in 2000 live births
- 0.3% are laryngeal clefts
- Boy:Girl… 5:3 ratio
- Associated with VACTERL, Opitz-Frias syndrome, Pallister-Hall syndrome
Embryology of Larynx
- Respiratory primordium develop from diverticulum on foregut
- Tracheobronchial groove arise on either side and fuse in the midline and for tracheoesophageal septum
- Fusion complete in 6th week of gestation
- Cricoid cartilage forms 5th week
- Incomplete fusion of tracheoesophageal septum or cricoid cartilage result in laryngeal cleft/T-E fistula
Laryngeal Development
Laryngeal Clefts
Benjamin and Inglis classification of laryngotracheal clefts
Type | Laryngotracheal Defect |
I | Supraglottic interarytenoid defect; the level of the cleft remains above the level of the (true) vocal cord |
II | The cleft extends below the level of the (true) vocal cords and partially into the cricoid cartilage |
III | The cleft extends completely through the posterior cricoid cartilage, with or without further extension into the cervical tracheo-esophageal wall |
IV | Common tracheo-esophagus that extends into the thorax and may extend all the way down to the carina |
Classification of Laryngeal Clefts
Clinical Significance
- Chronic Cough
- Aspiration
- Dysphagia
- Pneumonia
- Weight Loss
- Stridor
- Regurgitation
- Canosis
- Failure to Thrive
Current Methods of Treatment
- Diagnosis
- Rigid endoscopy +/- esophagoscopy
- Preoperative Modified Barium Swallow evaluation
- Conservative Management
- Anti-reflux medication
- Thickened feeds
- Positioning
- Nasogastric tube
- Age, comorbidity status, severity of aspiration, and the ability to tolerate a feeding regimen should be taken into account when deciding on conservative or surgical management for children with a type 1 laryngeal cleft.
Cleft Examples
Current Repair Methods
- Endoscopic Injection Laryngoplasty
- Bovine gelatin, Carboxymethylcellulose, Calcium hydroxylapatite, Collagen base, Hyaluranic acid base
- Filler material injected direct stab into the center of the interarytenoid area.
- Repeat injection often necessary
Current Repair Methods
- Endoscopic Surgical Repair
- Suspension laryngoscopy
- Edges of cleft denuded with microlaryngeal scissors or Co2 laser
- Denuded area apposed with 5.0 or 6.0 vicryl
- NG tube placed
- Intubation due to possible edema
- Pre/post op anti-reflux therapy
Current Repair Method
Rahbar R, Rouillon I, Roger G, et al. The Presentation and Management of Laryngeal Cleft: A 10-Year Experience. Arch Otolaryngol Head Neck Surg. 2006;132(12):1335-1341. doi:10.1001/archotol.132.12.1335.
New Techniques in Endoscopic Repair
- Type Laryngeal Cleft repair with Fibrin Sealant
- Proper candidate
- Suspension Laryngoscopy
- Insufflation or apneic technique
- Denude the interarytenoid region (cleft edges)
- Reapproximation of mucosa with Fibrin Sealant.
- NG tube placed
- Patient intubated x 24-48 hours
Fibrin Sealant
- Dunn C, Goa,K. Fibrin Sealant: A review of its use in surgery and endoscopy. Drugs 1999 Nov; 58 (5): 863-886
- www.tisseel.com
Postoperative Assessment
- Speech therapy consultation
- Modified Barium Swallow evaluation
- Functional endoscopic evaluation of swallow
***continue reflux therapy in the initial postoperative period.
Case 1
- 9mo otherwise healthy female
- Coughing, choking, frequent breaks during eating, croup cough, weight loss (FTT)
- Failed Modified Barium Swallow (MBSS) to all consistencies, with residual in pyriform
- Attempted laryngeal cleft repair
- After edema set in, fibrin glue was placed
- Postop MBSS
- No laryngeal penetration or primary aspiration
Case 2
- 2.5 month female with VACTERL
- Imperforate anus, tracheoesophageal fistula (TEF), esophageal atresia, ASD, Tricuspid Valve dysplasia
- At time of consult, imperforate anus and TEF s/p repair
- Patient with microaspiration, pulmonary infiltrates, failure to wean to extubate
- Rigid endoscopy revealed Type I cleft and tracheomalacia
- s/p repair patient extubated and decreased respiratory distress
- Unfortunately reintubated 1 month later after esophageal atresia repair. Scheduled for tracheostomy due to worsening tracheomalacia
Case 3
- 1.5 month female with hypoplastic left heart, VSD, tricuspid atresia s/p shunt day of life 2.
- At time of consult, patient stable but with unexplained cyanotic spells
- Characterized by cyanosis, choking, stridor desaturation, and tachycardia with spontaneous recovery
- Oral feeding stopped—spells decreased
- OPMS normal
- Barium swallow normal
- OR for assessment of cleft or fistula
- Dx with deep interarytenoid groove, type I cleft and mild laryngomalacia
- Spells ceased postop
- 4 week post op assessment patient with well healed cleft, minimal edema.
Traditional endoscopic Pros vs. Cons
- Injection Laryngoplasty
- Pros
- Decreased operative time
- Limited manipulation
- Cons
- Often requires repeat injection
- Laryngeal edema
- Overinjection
- Reaction to filler
- Endoscopic Stitch
- Pros
- Documented success rate
- Cons
- Longer operative time
- Increased manipulation (edema)
- Potential for technical difficulty
- Suture tracts shown to predispose to infections
- Infection along needle tracts
- Granulation formation
Fibrin Sealant Pros vs. Cons
- Endoscopic Fibrin Sealant
- Pros
- Decreased operative time
- Decreased manipulation
- Decreased technical difficulty
- Eliminates suture tracts
- Wound healing enhanced by immediate stimulation of fibroblasts
- Well documented in thoracic literature
- Cons
- Limited evidence based research in larynx
- Need ideal candidate
- Do not inject—risk of thromboembolic event
- Does not provide rigid fixation
References
- Dunn C, Goa,K. Fibrin Sealant: A review of its use in surgery and endoscopy. Drugs 1999 Nov; 58 (5): 863-886
- Itano H. The optimal technique for combined application of fibrin sealant and bioabsorable felt against alveolar air leakage. European Journal of Cardio-Thoracic Surgery 33 (2008) 457-460.
- Kang R, Leong H, et al. Sutureless Cartilage Graft Laryngotracheal Reconstruction Using Fibrin Sealant. Arch Otolaryngol Head Neck Surg 1998;124:665-670
- Kubba H, Bailey M, et al. Techniques and Outcomes of Laryngeal Cleft repair: An Update to the Great Ormond Street Hospital Series. Ann Otol Laryngol 114:2005
- Mallur P, Rosen C.Vocal Fold Injection : Review of Indications Techniques, and Materials For Augmentation. Clinical and Experimental Otorhinolaryngology Vol 3. No. 4: 177-182, Dec 2010
- Mangat H, Hakim H. Injection Augmentation of Type 1 Laryngeal Clefts. Otolaryngology -- Head and Neck Surgery 2012 146: 764 originally published online 18 January 2012. DOI: 10.1177/0194599811434004
- Rahbar R, Rouillon I, Roger G, et al. The Presentation and Management of Laryngeal Cleft: A 10-Year Experience. Arch Otolaryngol Head Neck Surg. 2006;132(12):1335-1341. doi:10.1001/archotol.132.12.1335.
- Remacle M, Matar N, Morsomme D, et al. Glottoplasty for male-to –female transsexualism: voice results. J Voice. 20011 Jan;25 (1): 120-3. Epub 2010 Feb 19.
- Wain J, Kaiser L, Johnstone D, et al. Trial of a novel synthetic sealant in preventing air leaks after lung resection. Ann Thorac Surg 2001;71:1623-1629. DOI: 10.1016/S0003-4975 (01)02537-1
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