Laryngomalacia is the most common laryngeal anomaly affecting newborns. Patient’s with severe disease should be considered for supraglottoplasty. It classically presents in a newborn with high-pitched inspiratory stridor that worsens with exertion, supine-positioning, and feeding. It is characterized by anatomic and physiologic abnormalities including shortened aryepiglottic (AE) folds, small, tightly curled epiglottis, redundant soft tissue overlying the cuneiform or accessory cartilages and reduced laryngeal tone. Any combination of these may present with laryngomalacia. Most cases are mild and resolve with observation or medical therapy.
1. Laser precautions are taken to protect patient and personnel.
2. Spontaneous ventilation
3. Suspension laryngoscopy is performed with adequate visualization of the larynx.
4. The operating telescope or microscope is used for visualization. The CO2 laser is tested.
5. First, division of the AE folds is performed.
6. Next, redundant mucosa and tissue overlying the accessory cartilages is ablated.
Severe disease including difficulty feeding, dyspnea on exertion, failure to thrive, obstructive hypoventilation, cyanosis, acute life threatening event, cor pulmonale
1. The head of the bed is turned 90 degrees. Our preference is to ventilate the patient spontaneously with intravenous anesthesia. Other options include jet ventilation, apnea techniques, or controlled ventilation with a small endotracheal tube.
2. Before performing the definitive surgery, the airway is evaluated with direct laryngoscopy and bronchoscopy to determine the presence of any synchonous airway lesions. The supraglottic and glottic structures are sprayed with lidocaine (maximum 4 mg/kg) for topical anesthesia.
3. Next, the larynx is exposed with a laryngoscope (we prefer the neonatal Lindholm). The laryngoscope is then suspended from a modified Mayo stand.
4. Laser precautions are taken to prevent airway fires and laser burns including wet eye pads and wet towels placed over the patient's head and over the suspension devices.
5. The operative telescope or microscope is brought in. Laser safe eyewear is provided to all OR personnel. The CO2 laser is pretested for accurate firing. We use the Omniguide laser with a setting of 4 watts continuous.
6. The CO2 laser is used to perform supraglottoplasty initially beginning with incisions through the aryepiglottic folds (AE) adjacent to the lateral aspect of the epiglottis. This is done by retracting the epiglottis or grasping the arytenoid mucosa with laryngeal cupped forceps to place the AE fold under tension. Start superiorly and extend inferiorly to the base of the epiglottis. The surgeon will often see immediate release of the tethered epiglottis.
7. Next, attention is turned to the redundant soft tissue and accessory cartilages overlying the arytenoids. The laser is used to debulk and ablate this tissue to prevent further prolapse of these structures into the airway. The surgeon must use caution and avoid the inter-arytenoid area medially because this could cause synechiae and supraglottic stenosis.
8. The patient may be emerged from anesthesia with endotracheal or mask ventilation. Patients should be monitored overnight and most are discharged from home the following day. Virtually all patients benefit from the use of reflex precautions and the treatment of gastroesophageal reflux in the perioperative period.
Flexible fiberoptic nasolaryngoscopy to assess the dynamic larynx and localize the area of most severe collapse and obstruction.
Aryepiglottic folds, epiglottis, arytenoids
Advocates of the CO2 laser state the advantage of surgical precision and meticulous hemostasis.