To Stitch or Not to Stitch: Laryngeal cleft type 1

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

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

1. Dunn C, Goa,K. Fibrin Sealant: A review of its use in surgery and endoscopy. Drugs 1999 Nov; 58 (5): 863-886
2. 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

1. Dunn C, Goa,K. Fibrin Sealant: A review of its use in surgery and endoscopy. Drugs 1999 Nov; 58 (5): 863-886
2. 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.
3. Kang R, Leong H, et al. Sutureless Cartilage Graft Laryngotracheal Reconstruction Using Fibrin Sealant. Arch Otolaryngol Head Neck Surg 1998;124:665-670
4. 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
5. 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
6. 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
7. 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.
8. 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.
9. 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