Transcervical Epiglottopexy for management of Type 3 Laryngomalacia

The patient was induced to a spontaneously breathing but sedated state with inhaled sevoflurane and intravenous propofol bolus, and subsequently maintained via administration of intravenous ketamine and propofol. A DLB was preformed which showed a large midline lingual thyroglossal cyst (TGC) in the vallecula and a posteriorly displaced epiglottis inverting over the glottic aperture. The child was then intubated with a 3.0 laser safe tube (Shiley™, Covidien, USA ) and subsequently placed in suspension with a toddler Benjamin Lindholm laryngoscope (Karl Storz Endoscopy America, Inc., El Segundo CA) with the aid of a self‐retaining laryngoscope holder secured to a Mayo stand. An operating microscope (Zeiss, Ontario CA) set to laryngeal work focal length was then used to visualize the surgical field. The Lumenis Ultrapulse Duo flexible fiber CO2 laser (Lumenis Inc, San Jose CA) was then brought into The field. Standard Laser safety precautions were followed. The lingual TGC was grasped with an alligator microlaryngeal forceps and the handheld laser was then used to dissect the cyst from the tongue and the lingual surface of the epiglottis. The cyst was removed en-bloc while simultaneously demucosalizing the lingual surface of the epiglottis and a TE was subsequently performed.

For TE, the surface marking for needle placement was just above the hyoid. The neck was sterilely prepped and draped and a 5 mm horizontal midline incision was made at the level of the hyoid and deepened to subcutaneous tissue to develop a pocket, wide enough to accommodate a 5 mm diameter silicone disc (Bentec Medical Inc.,) to support suture knots. An 18-gauge needle with pre-threaded 2-0 prolene suture (Ethicon) loop just proximal to the bevel of the needle, was inserted through the midline incision into the inferior vallecula and then through the epiglottis inferiorly in the midline, guided by endolaryngeal telescopic visualization.Once the needle location was confirmed endoluminally, the suture loop was advanced, grasped by alligator microlaryngeal forceps and brought out through the laryngoscope. The needle was then removed from the suture such that the free ends of the looped suture were still present transcervically and secured with hemostats. Next, a 20-gauge needle loaded with a single 2-0 Prolene suture with one free end passed through the needle lumen and inserted through the neck , passed over the hyoid and placed about half a centimeter superiorly to the previous stitch through the vallecula and the epiglottis . Once the needle was identified endoluminally, the suture was pushed through the needle. It was withdrawn superiorly with the grasper and taken out through the laryngoscope. A segment of suture was maintained exiting the neck at the puncture site. The needle was subsequently removed, and the sutures were secured with hemostats. The single Prolene suture was then threaded into the loop by the laryngoscopist while holding tension on the single suture with the surgeon at the neck pulling the loop. The looped suture is subsequently pulled through the neck . Once the loop exited the neck, the laryngoscopist released the single stitch, which was taken out the neck, leaving a single stitch precisely placed through the epiglottis. The free ends of the single stich in the neck was then secured over a custom trimmed 0.040-inch siliastic disc (Bentec Medical Inc.,) with two small puncture holes. The disc was placed within the wound pocket and the suture knot was tied onto the disc while observing the epiglottopexy endoscopically, without significantly distorting the epiglottis.
The wound was closed with 4-0 Monocryl. Tightened Aryepiglottic folds were then released bilaterally using the Laser.

1. Epiglottic Prolapse
2. Type Laryngomalacia

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