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

Video Published 2024-11-01 Updated 2026-08-01

Timestops (3)

Bronchoscopy Findings and Surgical Approach

Resection Technique and Postoperative Management

Cleft Closure Outcomes and Guidelines

Topic Overview

A surgical discussion of endoscopic repair for minor laryngeal clefts in children, presented by Dr. Catherine Hart at the 2022 QUAD Conference. The presentation emphasizes that combined rigid and flexible bronchoscopy is essential for diagnosis, as flexible bronchoscopy alone frequently misses type 1 clefts. Surgical indications include ongoing respiratory symptoms, aspiration, failure to thrive, or recurrent pulmonary infections when conservative measures fail. The endoscopic technique involves complete demucosalization of the interarytenoid mucosa with particular attention to the apex, followed by interrupted suture closure with inverted edges. Comparative outcomes show conservative management achieves 51% resolution, injection laryngoplasty 33% resolution, and surgical closure 70% resolution, though surgery carries higher complication risk including laryngeal scarring and supraglottic infections.

Key Takeaways

Combined rigid + flexible bronchoscopy is essential; flexible alone misses type 1 clefts that are visible on rigid scope. (0:53)
Complete demucosalization of the apex is critical—incomplete removal leaves a persistent hole causing continued aspiration. (2:42)
Surgical closure achieves 70% resolution vs 51% conservative management, but carries slightly higher complication risk. (4:09)
Cold steel resection is preferred over laser for minor clefts: simpler setup, faster, and eliminates laser fire risk. (2:23)
Edge inversion is essential for successful closure; taking suture bites too deeply inverts edges and causes persistent problems. (1:52)

Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Speaker 1 — host
M. Goddy — host
Dr. Catherine Hart — guest

Chapters

0:00Introduction and Diagnostic Challenges — Conference introduction and case presentation demonstrating that flexible bronchoscopy can miss laryngeal clefts that are visible on rigid bronchoscopy, emphasizing the need for combined evaluation techniques.
1:19Surgical Technique for Endoscopic Cleft Repair — Detailed description of the endoscopic repair procedure including indications, mucosal resection technique, suturing approach with edge inversion, and technical pitfalls to avoid.
3:10Postoperative Care and Comparative Outcomes — Discussion of postoperative management, failure patterns, comparative effectiveness of conservative management versus injection versus surgical closure, and complication profiles.
5:04Summary and Conclusion — Recap of key diagnostic and treatment principles for pediatric laryngeal clefts.

Key claims

0:53Flexible bronchoscopy can appear completely normal in a child with a type 1 laryngeal cleft that is visible on rigid bronchoscopy — Dr. Catherine Hart
1:09Combined rigid and flexible bronchoscopy evaluations are complementary and necessary to avoid missing laryngeal clefts — Dr. Catherine Hart
1:22Surgical indications for laryngeal cleft repair include ongoing respiratory symptoms, aspiration, failure to thrive, or recurrent pulmonary infections when other treatments have failed — Dr. Catherine Hart
1:45The goal of endoscopic cleft repair is to remove the interarytenoid mucosa to create two raw surfaces that are then sewn together — M. Goddy
1:52Edge inversion is essential for successful closure regardless of whether mass closure or layered closure technique is used — Dr. Catherine Hart
2:05Taking suture bites too deeply results in inverted edges and continued clinical problems — M. Goddy
2:23Interarytenoid mucosa can be resected using either laser or cold steel — M. Goddy
2:30Cold steel resection is preferred for minor clefts because it is simpler to set up, faster, and eliminates the risk of laser fire — Dr. Catherine Hart
2:42Complete demucosalization of the apex is critical; incomplete demucosalization results in a persistent hole at the apex and continued aspiration — M. Goddy
2:56Closure typically uses PDS suture on an RB1 or P3 needle depending on child size, with 2-3 interrupted sutures placed — Dr. Catherine Hart
3:01Epiglottic folds are released after suturing to create additional space — M. Goddy
3:10Postoperative protocol includes overnight observation on an airway unit, continuation of preoperative diet until follow-up, and repeat video swallow study and endoscopy at 6-8 weeks — Dr. Catherine Hart
3:29Surgical failure is not super common but can occur, often due to incomplete demucosalization at the apex resulting in healing at the top with a gap at the back — Dr. Catherine Hart
3:46Layered closure technique (closing anterior and posterior portions separately) is more reasonable for type 2 or 3 clefts but seems like excessive effort for minor clefts — Dr. Catherine Hart
4:09Conservative management achieves resolution over time in 51% of children with laryngeal clefts — Dr. Catherine Hart
4:24Injection laryngoplasty achieves symptom improvement in two-thirds of children and resolution in one-third — Dr. Catherine Hart
4:31Surgical cleft closure achieves symptom improvement in almost 80% of children and resolution in 70% — M. Goddy
4:36Surgical closure carries a slightly higher risk of complications compared to conservative management — M. Goddy
4:45Reported surgical complications include laryngeal scarring, supraglottic infections, and lacerations, though most complications are not terrible — Dr. Catherine Hart

Cases discussed

0:48Child with high clinical suspicion for laryngeal cleft demonstrating diagnostic challenge
3:29Surgical failure case demonstrating incomplete apex demucosalization

Open questions

What is the optimal timing for surgical intervention versus conservative management in children with laryngeal clefts
What is the best surgical technique (mass closure versus layered closure) for managing minor laryngeal clefts

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Keywords

laryngeal cleft type 1 cleft type 2 cleft type 3 cleft aspiration failure to thrive recurrent pulmonary infections laryngeal scarring supraglottic infections flexible bronchoscopy rigid bronchoscopy endoscopic laryngeal cleft repair injection laryngoplasty video swallow study endoscopy

Hashtags

#laryngeal cleft #endoscopic repair #pediatric ENT #airway surgery #dysphagia #Cincinnati Childrens #Globalcast MD #LaryngealCleft #PediatricENT #AerodigestiveMedicine #PediatricAirway #EndoscopicSurgery

Transcript

Globalcast MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hi everyone, I'm M. Goddy 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 Doctor Katherine Hart, an ENT surgeon at Cincinnati Children's, and Doctor Harth 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 cleft in Cincinnati, you can see this kid's got a type 1 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've failed all the other stuff, or in some instances before you even try all the other stuff, you operate on them. Endoscopic cleft repair can be a very, very simple procedure to do. The goal is to remove the internoid 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 inverted. 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. Scope and the key is to resect that interretinoid mucosa. Dr. Hardt 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 a laser fire if you don't use the 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 2 to 3 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 preop. Operative diet which they will remain on until their postoperative evaluation, which we typically do about 6 to 8 weeks after the surgery, and they will get a repeat video swallow study and a repeat endoscopy to ensure that there has 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. It seems like a lot more effort in these minor clefts to do it that way. In the type 2 or 3s, 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, 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 2/3 of kids with resolution in 1/3. 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. Patients 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, Doctor 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 interitinate mucosa and ensuring proper closure to prevent complications. Post-operative 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.

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