Supraglottoplasty

Description:

Supraglottoplasty addresses airway compromise in the supraglottis by correcting anatomic abnormalities of the aryepiglottic folds, posterior epiglottis, or tissue overlying the arytenoids. This may involve removal of excess or redundant tissue, division of shortened aryepiglottic folds to release tethered structures, and pexing (attaching) the epiglottis to the tongue base to prevent prolapse.

Indications for Surgery:

Laryngomalacia resulting in significant airway compromise, inability to feed, failure to thrive, or cardiopulmonary sequelae (e.g., cor pulmonale, pulmonary hypertension).

Contraindications to Surgery:

• Medical comorbidities that would preclude surgical or anesthesia risk
• The presence of concurrent airway anomalies may warrant consideration of alternative therapies
• Ongoing respiratory infection is a relative contraindication, although surgery may still be indicated if airway symptoms are severe enough

Pre-Operative Evaluation:

• Awake flexible fiberoptic laryngoscopy
• Other airway imaging is not typically performed, unless there is suspicion for concurrent airway anomalies
• A proton-pump inhibitor may be prescribed preoperatively to minimize inflammation during the procedure

Anesthesia:

General inhalation, spontaneous ventilation

Surgical Technique:

1. The patient is placed supine on the operating table and general anesthesia is induced via mask ventilation.
2. A Parsons laryngoscope is used to visualize the larynx and the vocal cords are sprayed with 1-2% lidocaine.
3. Mask ventilation is resumed for 1 minute.
4. A Lindholm or Parsons laryngoscope is inserted and a rigid endoscope is used to examine the larynx and trachea.
5. The laryngoscope is placed in suspension and the operating microscope is brought into position. Inhalation anesthesia is continued via delivery through the laryngoscope.
6. The CO2 laser is focused on the aryepiglottic fold and used to transect it laterally to reduce the redundancy of the arytenoid mucosa. Alternatively, scissors can be used to resect the redundant aryepiglottic folds.
7. A moistened pledget is used to remove excess char.
8. The procedure is repeated on the opposite side.
9. If an epiglottopexy is required, the laser is used to denude the epiglottic mucosa. The raw surface of the epiglottis is then adhered to the base of tongue with tacking sutures.
10. The Lindholm laryngoscope is taken off suspension and the Parsons laryngoscope is inserted.
11. The patient is then intubated and care is returned to the anesthesiologist for recovery.

Post-Operative Care:

• Extubation may be performed in the operating suite, or the patient may be kept intubated in the immediate postoperative period, depending on disease severity and other patient factors.
• A postoperative course of steroids reduces airway edema related to surgery.
• Criteria for discharge include adequate ventilation on room air and ability to feed.
• The patient is discharged on a proton-pump inhibitor to minimize the effects of reflux on healing.
• Follow-up is scheduled 2 weeks after surgery, at which time a repeat flexible fiberoptic laryngoscopic exam may be performed.

Complications:

• Transient dysphagia
• Transient aspiration
• Treatment failure (persistent laryngomalacia)
• Supraglottic stenosis