A modified Edmonton repair for type 1 laryngeal cleft

This is a modificatied technique for endoscopic repair of LC1 in children using cold steel instruments, with detailed description of the ergonomics that would help its mastery. 1. Airway endoscopy and exposure a. A complete flexible and rigid endoscopic examination of the airway is universally undertaken, during which topical lidocaine (1%) is applied onto the supraglottis and glottis. A right-angle laryngeal probe is used to palpate the inter-arytenoid (IA) area to assess its depth. Then, the larynx is exposed using an age-appropriate Benjamin-Lindholm laryngoscope and suspended over a Mayo stand. Supplemental oxygen is insufflated into the airway using a side port adaptor connected to the anesthetic circuit. An operating microscope with a 400 mm focal distance is used. b. A white sheet is wrapped over the face and around the laryngoscope to provide a contrasting background for easier visualization of the suture and to avoid entanglement to the patient’s hair and suspension equipment. 2. Creation of the IA incision a. Lidocaine (1%) with epinephrine (1:100,000) is injected into the submucosa of the IA area (0.2-0.3 ml) using a 25-gauge butterfly needle held with a micro-laryngeal cupped forceps. The posterior aspect of the IA mucosa is grasped and pulled posteriorly using a 45-degree Alligator forceps. Using a left-curving Kleinsasser micro-laryngeal scissor, a mucosal incision is created in the IA area in a coronal plane and extended over the medial surface of each arytenoid cartilage, without violating the cartilage. The incision is deepened through the submucosa, creating visible anterior and posterior lips. Hemostasis is maintained with intermittent use of 1:1000 epinephrine-soaked pledgets. b. The surgeon works with the elbow supported on the elevated arms of a surgical chair and the surgical bed is tilted in a reverse Trendlenberg position. The shafts of the micro-laryngeal instruments lean against the edges of the laryngoscope to better control the torque at the distal end of instruments. 3. Suture placement The mucosal edges are then approximated in the sagittal plane (one half of each lip to its counterpart). Polydioxanone (PDS II) 7-0 suture on a BV-1, 9.3 mm curved, tapered needle is used (Z135H, Ethicon®). Four interrupted inverting sutures are taken, allowing the knots to be buried, two for each lip of the incision. Suturing starts in the paramedian plane of the anterior lip of the incision. The second suture is placed more laterally, approximating the mucosa over the shoulders of the arytenoids. The third and fourth sutures are taken in the posterior lip of the incision, proceeding from more lateral to paramedian. We ensure taking sufficient bites of mucosa for a reliable closure while avoiding passing the sutures through the arytenoid cartilages. 4. Handling the needle The needle is held with a micro-laryngeal Kleinsasser forceps with a ratchet. For the paramedian sutures, the needle is held in the long axis of the instrument. It is inserted into the mucosa in a stab-like fashion, forward upon taking the initial pass within the wound and in reverse for the second pass through the mucosal side. When addressing the the lateral suture for the anterior lip, the needle is mounted in a 45-degree angle to the long access of the needle holder, going forward in the first pass (on the left edge for the right handed surgeon) and then mounted in a 135 degree angles, in reverse, for the second pass (on the right edge). Upon undertaking the lateral sutures for the posterior lip, all the angles and orders are reversed. Figure 2 illustrates the needle orientation for every pass. The IA mucosa is manipulated gently using the 45-degree miniature grasping forceps for counter-traction and optimal exposure. The shafts of the instruments are supported against the sides of the laryngoscope to better control the torque at the distal end of instruments. The surgeon palms the needle driver rather than inserting both his/her fingers to avoid accidental unlocking. Attention is paid to supination of the surgeon’s wrist while undertaking the first pass in the anterior lip versus pronating it in the second pass, and following the reverse for the posterior lip. 5. Knotting Once the intended throws are taken, with the help of an assistant one end is held diagonally across the opening of the laryngoscope while maintaining tension. This improves the visibility of the thread, helping the surgeon to aim the knot pusher at the thread. The knot is glided towards the wound along the length of the suture rather than on the knot itself. The assistant maintains adequate tension until each knot is secured. All the instruments and sutures are kept moistened with normal saline in order to mitigate the effect of dryness on the suture material and the instruments.

The presence of a type 1 laryngeal cleft. a. Type 1 laryngeal cleft (LC1) is a deficiency in the tissues of the interarytenoid (IA) area that does not extend below the level of the true vocal cords and does not involve the cricoid cartilage. This is the mildest type of laryngeal clefts based on the classification described by Benjamin and Inglis. b. The association between LC1 and swallowing dysfunction (SwD) is supported by the improvement in swallowing function after repair of LC1.

1. Difficult laryngeal view, grade three Lehane McCormack 2. Absence of obvious anatomical cleft 3. Poor pulmonary reserve prohibiting the maintenance of spontaneous respiration for 25 minutes (the duration of the procedure)

Anesthesia:After induction of general anesthesia using either inhalational (sevoflurane) or total intravenous agents (TIVA; propofol and remifentanil), spontaneous respiration is maintained using TIVA. One dose of dexamethasone is administered intravenously, and no antibiotics are used. Patient positioning: The patient is placed in the supine position, and the neck is extended using a shoulder roll. The table height is adjusted in a slight reverse Trendelenburg position, allowing the surgeon to work comfortably with the knee and hip joints nearly at right angles. The surgical chair with armrests supports the elbows throughout the procedure. Airway endoscopy and exposure: A complete flexible and rigid endoscopic examination of the airway is universally undertaken, during which topical lidocaine (1%) is applied onto the supraglottis and glottis. A right-angle laryngeal probe is used to palpate the IA area to assess its depth. Then, the larynx is exposed using an age-appropriate Benjamin-Lindholm laryngoscope and suspended over a Mayo stand. Supplemental oxygen is insufflated into the airway using a side port adaptor connected to the anesthetic circuit. An operating microscope with a 400 mm focal distance is used. We emphasize using a tubeless technique with the patient breathing spontaneously for multiple reasons. First, this affords unimpeded visualization and instrumentation. Second, the IA area remains in a neutral, undisrupted position, allowing more precise surgical work. Third, potential irritation of the airway by an endotracheal tube is avoided. This can reduce the risk of edema and disruption of sutures and contributes to a smoother emergence from anesthesia. We prefer to use synthetic monofilament polydioxanone (PDS II). This is a newer form of PDS with decreased stiffness, easier handling, and improved knot reliability. It also has improved and prolonged tensile strength compared to Vicryl. The smoothness of the material also allows for easier gliding action when pushing the knots.

Functional Endoscopic Evaluation of the Swallow (FEES) is performed to assess swallowing function and airway protection, and particularly to assess for penetration and/or aspiration. VFSS can also be done to assess aspiration risk, although this exposes the patient to radiation. Rigid airway endoscopy performed to identify the type 1 laryngeal cleft.

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The detailed description of ergonomics and the optimal handling of instruments and sutures addresses many of the challenges and potential pitfalls of the procedure. We emphasize using a tubeless technique with the patient breathing spontaneously for multiple reasons. First, this affords unimpeded visualization and instrumentation. Second, the IA area remains in a neutral, undisrupted position, allowing more precise surgical work. Third, potential irritation of the airway by an endotracheal tube is avoided. This can reduce the risk of edema and disruption of sutures and contributes to a smoother emergence from anesthesia. We prefer to use synthetic monofilament polydioxanone (PDS II). This is a newer form of PDS with decreased stiffness, easier handling, and improved knot reliability. It also has improved and prolonged tensile strength compared to Vicryl. The smoothness of the material also allows for easier gliding action when pushing the knots. In our practice, the cold steel technique has proven precise, safe, and efficient when fashioning the mucosal incision. The incision is made accurately in the depth of the cleft and through the thin mucosa close to the body of the arytenoids. Bleeding is usually scant and can be controlled easily with topical epinephrine (1:1000), which obviates any thermal effect on the tissues. We favor multiple (3-4) sutures for a more reliable and precise augmentation, resulting in a higher and wider IA mound (anteroposteriorly) without risking posterior glottic stenosis or ankylosing the arytenoids. We bury the knots, potentially decreasing the risk of granuloma formation and irritation. Additionally, the technique attends to the ergonomics of needle handling and planning the passes. This results in efficient use of time and a smooth flow. The details described allow for coaching the trainees for mental preparedness with specific reasoned steps. Finally, using a tubeless, fast, and atraumatic technique, we found that all our patients had a smooth postoperative course without requiring intubation or prolonged hospital stay. Following these surgical steps and ergonomic tips the duration of the procedure does not exceed 30 minutes We have not found any need to divide the aryepiglottic folds as the steps do not narrow the laryngeal inlet like other techniques. This avoids possible alterations to the neural supply from the superior laryngeal nerve which may cause swallowing dysfunction in its own right postoperatively.

Our series holds 10 percent repair breakdown and 25% failure to resolve swallowing dysfunction.

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