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

overzicht 1

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

overzicht 2

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

Laryngeal cleft type 1

laryngeal cleft 2

laryngeal cleft type 3

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

Current repair methods

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

laryngeal cleft preop 1

laryngeal cleft preop 2

laryngeal cleft preop 3

laryngeal cleft preop 4

Fibrin Sealant

Fibrin Sealant 1.

  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