QUAD #20: Endoscopic Repair of Minor Laryngeal Clefts with Dr. Catherine Hart

Globalcast MD along with Cincinnati Children's Hospital sharing knowledge to improve child health around the globe. Hi everyone. I'm M. Goudy from Cincinnati Children's Hospital Medical Center. In October 2022, Cincinnati Children's hosted the Quad conference, which was a combination of four conferences. The International Organization for Esophageal Atresia, the Aerodigestive Society Conference, the Cincinnati Children's Airway Course, and the Cincinnati Children's Pediatric Dysphagia Series. In this video, we are going to discuss Endoscopic Laryngeal Cleft Repair with Dr. Katherine Hart, an ENT surgeon at Cincinnati Children's. And Dr. Hart started with a case. Here we see a combination of both rigid and flexible bronchoscopy recordings. This is a child we had a really high index of suspicion had a cleft, and you can see there that that looks incredibly normal on that flexible bronchoscopy. And even here, using the less sophisticated technique that we use to identify clefts in Cincinnati, you can see this kid's got a type one cleft. That's the exact same larynx, and they look incredibly different. So I think this really speaks to the importance of these combined evaluations that we do, and those two evaluations are truly complementary, and you miss stuff if you don't do them both. The question as a surgeon is, when should I be operating on it? There's a lot of controversy about the timing of all of this, but really what it boils down to is if you have a child who's got ongoing respiratory symptoms, they're having aspiration, they're failing to thrive, they're having recurrent pulmonary infections, and they failed all the other stuff, or in some instances, before you even try all the other stuff, you operate on them. And this c cleft repair can be a very, very simple procedure to do. The goal is to remove the inter-arenoid mucosa. You have two raw surfaces and then you are going to sew the edges together. It doesn't matter if you do this in a mass closure technique or a layered closure technique, but the key is when you're done, you have to make sure that your edges are everted. If they're not, you're going to continue to have issues. So this is the difference. If you're taking your bites too deeply, you end up with inverted edges and you will continue to have an issue with that child. This is what it looks like in real time. You're going to suspend the child with whatever approach you choose to use. We do this with a microscope, and the key is to resect that inter-retinoid mucosa. Dr. Hart states that it doesn't really matter how you resect it. You can use a laser or a knife, aka cold steel in the surgery world. I always prefer to go with cold steel, especially on the minor ones, because it's more simple to set up and you can't have the laser fire if you don't use a laser. That's why we typically do it this way, and it's just a heck of a lot faster. The key step here is making sure the apex is completely demucosalized. If it's not, you're going to have a little hole at the apex and that child is going to continue to aspirate. And then you quite simply close it using some interrupted sutures. We typically use a PDS on an RB1 or a P3 needle depending on the size of the child. They typically throw two to three sutures depending on the extent of the cleft. And once they've done that, they will release the epiglottic folds just to create a little extra space. We'll observe these children overnight on our airway unit, and we will resume their preoperative diet, which they will remain on until their post-operative evaluation, which we typically do about six to eight weeks after the surgery, and they will get a repeat video swallow study and a repeat endoscopy to ensure that there's been healing going on. So this doesn't always work. Failure is not super common. This one was not probably completely demucosalized at the apex. So it healed at the top, but there's a nice little gap there at the back. This case is not very subtle, but they can be a lot more subtle than this, and then you have to start over. You can do this in a layered closure technique where you close the anterior portion and the posterior portion separately. This seems like a lot more effort in these minor clefts to do it that way. In the type two or threes, it is certainly a more reasonable option to ensure good closure. There's been a lot of discussion about what's the best option. Unfortunately, we don't really know what the best option is to manage these kids. When you compare conservative management, other different therapies in either injection or surgical closure, you get resolution over time in 51% of kids. So by doing not nothing, but not doing surgery, you can still get improvement in a lot of patients. When you look at injection laryngoplasty in this big group, they get improvement in symptoms in two-thirds of kids with resolution in one-third. And if you just go ahead and close the cleft, you get improvement in symptoms in almost 80% of the kids. Resolution in 70%, but you do have a slightly higher risk of complications because now you're doing something versus just a conservative management. In a lot of instances the complications are not terrible, but there are reports of some laryngeal scarring, supraglottic infections and lacerations. Here, Dr. Hart shared this consensus guideline, which is a really good resource, especially if you're newer to practice. Thinking of organizing your thoughts about how to look at these kids. In summary, accurately diagnosing and treating laryngeal clefts in children is crucial and often requires combined evaluations. Surgery is considered when children have ongoing respiratory issues, aspiration, or recurrent infections. Endoscopic repair is superior to the other options in terms of resolution of aspiration and reduction in symptoms, and it involves removing the inter-retinoid mucosa and ensuring proper closure to prevent complications. Postoperative care includes close monitoring and follow-up evaluations. You can also get a reduction in symptoms in a lot of patients with just conservative management. Thank you for watching this video. Don't forget to subscribe to the stay current MD YouTube channel. Follow our social media channels and download the Stay Current MD app for tons of content in pediatric surgery. Globalcast MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.