Endoscopic Anterior and Posterior Cricoid Split

This video provides an elucidation of the surgical steps involved in performing an endoscopic anterior and posterior cricoid split in a neonate with bilateral vocal fold paralysis.

Following the administration of general anesthesia, the patient was appropriately positioned and subjected to pediatric laryngoscopy with suspension. Spontaneous breathing was facilitated through the use of side port insufflation. A vocal fold retractor was applied to enable a comprehensive examination of the entire airway using a telescope. The posterior cricoid plates were injected with 1% lidocaine containing 1:100,000 epinephrine using a butterfly needle. A midline posterior cricoidotomy was performed using the cold steel technique with a microlaryngeal round knife. The complete division of the posterior cricoid lamina was visualized with the assistance of a microlaryngeal curved alligator. The same technique was employed to divide the anterior cricoid lamina. Subsequently, balloon dilatation was performed to expand the divided cricoid ring for a duration of 40 seconds or until oxygen desaturation (SpO2 < 90%) occurred. The size of the balloon used was based on the outer diameter of a half-size larger than the age-appropriate endotracheal tube. At the end, nasotracheal intubation with a half-size larger than the age-appropriate endotracheal tube was carried out.
Pediatric bilateral vocal fold paralysis
Difficult laryngeal exposure. Not fit for general anesthesia.
Pediatric laryngoscopy with suspension. Spontaneous breathing aided by side port insufflation.
Routine preoperative work up of bilateral vocal fold immobility.
Alternate procedures for neonate bilateral vocal fold paralysis include suture lateralization and tracheostomy.
Advantage: Less operative time, avoid tracheostomy. Disadvantage: Need for prolonged intubation up to 2 weeks, might need an additional balloon dilation.
Laryngeal edema and injury to vocal fold or surrounding structures, complication from prolonged intubation.
Rutter MJ, Hart CK, Alarcon A, et al. Endoscopic anterior-posterior cricoid split for pediatric bilateral vocal fold paralysis. Laryngoscope. 2018;128(1):257-263. doi:10.1002/lary.26547

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