Supraglottoplasty in infants using sinus instruments.

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​2a-​-c).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.