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Tan L, Li Q, Chen C. Outcomes of surgical repair of Type III and IV laryngotracheoesophageal clefts with posterior cartilage grafting. Eur Arch Otorhinolaryngol 2024:10.1007/s00405-024-08701-1. [PMID: 38761217 DOI: 10.1007/s00405-024-08701-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 04/20/2024] [Indexed: 05/20/2024]
Abstract
PURPOSE To describe the clinical outcomes of patients who underwent surgical repair through an anterior approach that involved interposition a posterior cartilage for Type III or Type IV laryngotracheoesophageal cleft (LTEC). METHODS A chart view was performed on patients with Type III or Type IV LTEC between May 2017 and May 2022. Demographic features and surgical outcomes were collected and analyzed. RESULTS Seven patients were finally included. Five patients were diagnosed with Type III LTEC and two patients were diagnosed with Type IV LTEC. All but one patients survived and thrived. Four patients were able to successfully extubate with acceptable voice, and two patients were tracheostomized. Five patients were deemed safe for all consistencies food and one was safe for thickened food. After a mean follow-up of 49 months (18-83 months), neither complications nor recurrences were observed. CONCLUSION An anterior laryngofissure approach to the cleft repair with a posterior cartilage grafting is an effective and safe treatment for Type III or IV LTEC, which enables closure of LTEC and reconstruction of cricoid plate in order to avoid tracheoesophageal fistula formation or subglottic stenosis postoperatively. Severe tracheomalacia and GERD are two main causes for surgical failure.
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Affiliation(s)
- Letian Tan
- Department of Otolaryngology-Head and Neck Surgery, Children's Hospital of Fudan University, Shanghai, 201102, China
| | - Qi Li
- Department of Otolaryngology-Head and Neck Surgery, Children's Hospital of Fudan University, Shanghai, 201102, China
| | - Chao Chen
- Department of Otolaryngology-Head and Neck Surgery, Children's Hospital of Fudan University, Shanghai, 201102, China.
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Abstract
Laryngeal webs and laryngotracheoesophageal clefts (LTECs) are rare malformations of the larynx. Both can have a wide range of symptoms. While webs typically affect voice and airway and LTECs typically affect swallowing and airway, this is not always the case. A high index of suspicion is required for timely and accurate diagnosis. A discussion of management and treatment options will be presented. Both endoscopic and open surgical techniques exist for both pathologies and will be reviewed.
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Hackenberg S, Kraus F, Scherzad A. Rare Diseases of Larynx, Trachea and Thyroid. Laryngorhinootologie 2021; 100:S1-S36. [PMID: 34352904 PMCID: PMC8363221 DOI: 10.1055/a-1337-5703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
This review article covers data on rare diseases of the larynx, the trachea and the thyroid. In particular, congenital malformations, rare manifestations of inflammatory laryngeal disorders, benign and malignant epithelial as well as non-epithelial tumors, laryngeal and tracheal manifestations of general diseases and, finally, thyroid disorders are discussed. The individual chapters contain an overview of the data situation in the literature, the clinical appearance of each disorder, important key points for diagnosis and therapy and a statement on the prognosis of the disease. Finally, the authors indicate on study registers and self-help groups.
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Affiliation(s)
- Stephan Hackenberg
- Klinik und Poliklinik für Hals-, Nasen- und Ohrenkrankheiten,
plastische und ästhetische Operationen, Universitätsklinikum
Würzburg
| | - Fabian Kraus
- Klinik und Poliklinik für Hals-, Nasen- und Ohrenkrankheiten,
plastische und ästhetische Operationen, Universitätsklinikum
Würzburg
| | - Agmal Scherzad
- Klinik und Poliklinik für Hals-, Nasen- und Ohrenkrankheiten,
plastische und ästhetische Operationen, Universitätsklinikum
Würzburg
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Jáuregui EJ, Propst EJ, Johnson K. Current management of type III and IV laryngotracheoesophageal clefts: the case for a revised cleft classification. Curr Opin Otolaryngol Head Neck Surg 2020; 28:435-442. [PMID: 33109943 PMCID: PMC8966410 DOI: 10.1097/moo.0000000000000669] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE OF REVIEW This review summarizes the paediatric laryngotracheoesophageal cleft (LTEC) literature, with an emphasis on recent trends, evaluation and management, surgical techniques, postoperative care of Type III and IV LTECs, and to propose a revised cleft classification system that more accurately reflects our current understanding of these anomalies. RECENT FINDINGS There are a number of techniques described to address Type III and IV LTEC, from endoscopic to open approaches with thoracotomy. The surgical approach should be tailored to the length of the cleft and its proximity to important anatomical structures. On the basis of review of the literature, we propose a modified Benjamin-Inglis classification (MBI) with subcategories to address this issue. Postoperative complications are common, namely, tracheoesophageal fistulae and tracheomalacia, which may necessitate subsequent procedures or prolonged tracheostomy dependence. SUMMARY The medical and surgical management of Type III and IV LTEC is challenging with a high rate of morbidity and mortality. The rarity and difficulties in management of these malformations have made large cohort studies difficult, thus generalizable recommendations have been elusive. Experience and patient selection are critical for successful endoscopic repair. Anterior cervical approach, often with complete laryngofissure, appears to be the most common and preferred method for open repairs, though some use a lateral approach. The proposed MBI classification appears to be a useful adjunct to aid in surgical decision-making for deeper LTEC.
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Affiliation(s)
- Emmanuel J. Jáuregui
- University of Washington, Department of Otolaryngology—Head & Neck Surgery and Seattle Children’s Hospital, Seattle, Washington, USA
| | - Evan J. Propst
- Department of Otolaryngology—Head & Neck Surgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Kaalan Johnson
- University of Washington, Department of Otolaryngology—Head & Neck Surgery and Seattle Children’s Hospital, Seattle, Washington, USA
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5
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Repair of type IV laryngotracheoesophageal cleft (LTEC) on ECMO. Pediatr Surg Int 2019; 35:565-568. [PMID: 30783751 DOI: 10.1007/s00383-019-04455-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/08/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE A type IV laryngotracheoesophageal cleft (LTEC) is a very rare congenital malformation. Type IV LTEC that extends to the carina have poor prognosis and are difficult to manage. We present our experience with surgical repair in such a case using extracorporeal membranous oxygenation (ECMO). METHODS A male infant, who was diagnosed with Goldenhar syndrome, showed severe dyspnea and dysphagia. Laryngoscopy indicated the presence of LTEC. The patient was transferred to our institute for radical operation 26 days after birth. Prior to surgery, a balloon catheter was inserted in the cardiac region of stomach through the lower esophagus to block air leakage, to maintain positive pressure ventilation. We also performed observations with a rigid bronchoscope to assess extent of the cleft, and diagnosed the patient with type IV LTEC. After bronchoscopy, we could intubate the tracheal tube just above the carina. Under ECMO, repair of the cleft was performed by an anterior approach via median sternotomy. RESULTS The patient was intubated via nasotracheal tube and paralysis was maintained for 2 weeks, using a muscle relaxant for the first 3 days. Two weeks after surgery, rigid bronchoscopy showed that the repair had been completed, and the tracheal tube was successfully extubated without tracheotomy. CONCLUSIONS Although insertion of a balloon catheter is a very simple method, it can separate the respiratory and digestive tracts. This method allowed for positive pressure ventilation and prevented displacement of the endotracheal tube until ECMO was established. As a result, we safely performed the operation and the post-operative course was excellent.
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Abstract
Diagnosis and treatment of laryngeal clefts (LCs) particularly type I pose a challenge. Although rare, type I LCs are becoming increasingly identified in recent years, and this is perhaps due to both an increased awareness and better diagnostic modalities. We report a young infant presenting with feeding difficulty and respiratory distress related to LC. The pertinent literature is also reviewed.
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Abstract
This article reviews congenital anomalies involving the larynx and trachea, including congenital subglottic stenosis, laryngeal webs, laryngeal cleft, and tracheal stenosis. Presenting signs and symptoms, prevailing surgical repair techniques, and postoperative care are discussed.
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Affiliation(s)
- April M Landry
- Department of Otolaryngology Head and Neck Surgery, Emory University, 1600 Tullie Road NE, Atlanta, GA 30329, USA.
| | - Michael J Rutter
- Department of Otolaryngology Head and Neck Surgery, University of Cincinnati, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
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8
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Type IV Laryngotracheoesophageal Cleft Associated with Type III Esophageal Atresia in 1p36 Deletions Containing the RERE Gene: Is There a Causal Role for the Genetic Alteration? Case Rep Pediatr 2018; 2018:4060527. [PMID: 30245899 PMCID: PMC6136558 DOI: 10.1155/2018/4060527] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Revised: 07/09/2018] [Accepted: 08/01/2018] [Indexed: 01/02/2023] Open
Abstract
The causes of embryological developmental anomalies leading to laryngotracheoesophageal clefts (LTECs) are not known, but are proposed to be multifactorial, including genetic and environmental factors. Haploinsufficiency of the RERE gene might contribute to different phenotypes seen in individuals with 1p36 deletions. We describe a neonate of an obese mother, diagnosed with type IV LTEC and type III esophageal atresia (EA), in which a 1p36 deletion including the RERE gene was detected. On the second day of life, a right thoracotomy and extrapleural esophagus atresia repair were attempted. One week later, a right cervical approach was performed to separate the cervical esophagus from the trachea. Three months later, a thoracic termino-terminal anastomosis of the esophagus was performed. An anterior fundoplication was required at 8 months of age due to severe gastroesophageal reflux and failure to thrive. A causal role of 1p36 deletions including the RERE gene in the malformation is proposed. Moreover, additional parental factors must be considered. Future studies are mandatory to elucidate genomic and epigenomic susceptibility factors that underlie these congenital malformations. A multiteam approach is a crucial factor in the successful management of affected patients.
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9
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Laryngeal cleft type IV: One pathology, two different presentations. Int J Pediatr Otorhinolaryngol 2018; 109:154-157. [PMID: 29728171 DOI: 10.1016/j.ijporl.2018.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 04/05/2018] [Accepted: 04/08/2018] [Indexed: 11/24/2022]
Abstract
Laryngotracheoesophageal cleft is a rare congenital malformation where a communication exists between the aero-digestive tracts that is associated with high morbidity and mortality. In this case series, we describe our experience with two neonates evaluated in our institution with two diverse initial presentations and symptomatology of type IV laryngotracheoesophageal clefts. One patient presented with acute distress and respiratory failure due to bowel contents obstructing the trachea and the other presented with mild subcostal retractions and inspiratory stridor without overt respiratory failure. Most importantly, not every patient with type IV laryngotracheoesophageal clefts will present with fulminant respiratory difficulty. This prompted a literature review.
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10
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Revision repair of type IV laryngotracheoesophageal cleft using multiple long tapered engaging grafts. Int J Pediatr Otorhinolaryngol 2017; 103:80-82. [PMID: 29224771 DOI: 10.1016/j.ijporl.2017.10.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 10/05/2017] [Accepted: 10/06/2017] [Indexed: 11/20/2022]
Abstract
An 8 year-old female with esophageal atresia and a type IV laryngotracheoesophageal cleft underwent tracheostomy, gastric pull-up and fundoplication with G-tube insertion at birth. She remained nil per os due to aspiration. The trachealis was separated from the esophagus that was reapproximated and clavicular periosteum was placed. A long posterior costal cartilage graft that engaged behind the cricoid plate and tapered inferiorly was inserted. A second thin cartilage graft was sutured to it distally to extend the length of the repair. This allowed for removal of the tracheostomy and oral feeding while providing a four-layer closure to prevent aspiration.
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11
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Vuncannon J, Albanna M, Evans AK. The adaptive use of a hand-crafted endotracheal-endobronchial tube for airway management in laryngo-tracheo-esophageal cleft type IV. Int J Pediatr Otorhinolaryngol 2017; 98:71-74. [PMID: 28583508 DOI: 10.1016/j.ijporl.2017.04.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 04/27/2017] [Accepted: 04/30/2017] [Indexed: 10/19/2022]
Affiliation(s)
| | | | - Adele K Evans
- Wake Forest School of Medicine, Department of Otolaryngology, United States.
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12
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Sonmez K, Karabulut R, Turkyilmaz Z, Turkyilmaz C, Isik B, Eryilmaz S, Seref K, Ozcan E, Hosgoren GM, Basaklar AC. Our experience in two cases of type IV laryngotracheoesophageal cleft (LTEC) with a diagnosis of antenatal esophageal atresia. Pan Afr Med J 2017; 26:55. [PMID: 28451032 PMCID: PMC5398864 DOI: 10.11604/pamj.2017.26.55.10647] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 11/02/2016] [Indexed: 11/11/2022] Open
Abstract
Laryngotracheoesophageal clefts (LTECs) are rare congenital defects that are often accompanied by additional anomalies. The major issues in the treatment of these patients are intraoperative exposure insufficiency, technical difficulty of the operation, and anesthesia problems originating from the respiratory tract. Problems originating from mechanical ventilation and respiratory tract, eating disorders and relapse of fistula are among the problems encountered following surgery. Most of the time, concomitant additional anomalies also worsen the clinical picture. It was our aim with these case reports to report our experience in two cases with Type IV LTEC ranging from the inoperable type IV LTEC due to additional anomalies mounted up to severe respiratory distress to the carina that we operated on with a single stage anterior cervicothoracic approach on its fifth day on life.
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Affiliation(s)
- Kaan Sonmez
- Gazi University, Faculty of Medicine, Departments of Pediatric Surgery, Ankara, Turkey
| | - Ramazan Karabulut
- Gazi University, Faculty of Medicine, Departments of Pediatric Surgery, Ankara, Turkey
| | - Zafer Turkyilmaz
- Gazi University, Faculty of Medicine, Departments of Pediatric Surgery, Ankara, Turkey
| | - Canan Turkyilmaz
- Neonatology Gazi University, Faculty of Medicine, Ankara, Turkey
| | - Berrin Isik
- Anesthesiology and Reanimation, Gazi University, Faculty of Medicine, Ankara, Turkey
| | - Sibel Eryilmaz
- Gazi University, Faculty of Medicine, Departments of Pediatric Surgery, Ankara, Turkey
| | - Kıvanc Seref
- Gazi University, Faculty of Medicine, Departments of Pediatric Surgery, Ankara, Turkey
| | - Ebru Ozcan
- Neonatology Gazi University, Faculty of Medicine, Ankara, Turkey
| | - Gul Meral Hosgoren
- Anesthesiology and Reanimation, Gazi University, Faculty of Medicine, Ankara, Turkey
| | - Abdullah Can Basaklar
- Gazi University, Faculty of Medicine, Departments of Pediatric Surgery, Ankara, Turkey
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Mok Q. Airway Problems in Neonates-A Review of the Current Investigation and Management Strategies. Front Pediatr 2017; 5:60. [PMID: 28424763 PMCID: PMC5371593 DOI: 10.3389/fped.2017.00060] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 03/10/2017] [Indexed: 11/20/2022] Open
Abstract
Airway problems in the neonatal population are often life threatening and raise challenging issues in diagnosis and management. The airway problems can result from congenital or acquired lesions and can be broadly classified into those causing obstruction or those due to an abnormal "communication" in the airway. Many different investigations are now available to identify the diagnosis and quantify the severity of the problem, and these tests can be simple or invasive. Bronchography and bronchoscopy are essential to determine the extent and severity of the airway problem and to plan treatment strategy. Further imaging techniques help to delineate other commonly associated abnormalities. Echocardiography is also important to confirm any associated cardiac abnormality. In this review, the merits and disadvantages of the various investigations now available to the clinician will be discussed. The current therapeutic strategies are discussed, and the review will focus on the most challenging conditions that cause the biggest management conundrums, specifically laryngotracheal cleft, congenital tracheal stenosis, and tracheobronchomalacia. Management of acquired stenosis secondary to airway injury from endotracheal intubation will also be discussed as this is a common problem. Slide tracheoplasty is the preferred surgical option for long-segment tracheal stenosis, and results have improved significantly. Stents are occasionally required for residual or recurrent stenosis following surgical repair. There is sufficient evidence that a multidisciplinary team approach for managing complex airway issues provides the best results for the patient. There is ongoing progress in the field with newer diagnostic tools as well as development of innovative management techniques, such as biodegradable stents and stem cell-based tracheal transplants, leading to a much better prognosis for these children in the future.
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Affiliation(s)
- Quen Mok
- Pediatric and Neonatal Intensive Care Units, Critical Care Division, Great Ormond Street Hospital for Children, London, UK
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14
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Parkes WJ, Propst EJ. Advances in the diagnosis, management, and treatment of neonates with laryngeal disorders. Semin Fetal Neonatal Med 2016; 21:270-6. [PMID: 27049674 DOI: 10.1016/j.siny.2016.03.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Neonatal airway obstruction due to laryngeal pathology may cause significant morbidity and even mortality. The most frequently occurring etiologies anatomically from superiorly to inferiorly include: laryngomalacia, saccular cyst, vocal fold paralysis, anterior glottic web, laryngeal atresia, laryngeal cleft, subglottic stenosis, and subglottic hemangioma. The pathophysiology, presentation, and treatment options for each of these entities are discussed with a focus on a multidisciplinary, evidence-based approach.
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Affiliation(s)
- William J Parkes
- Hospital for Sick Children, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Evan J Propst
- Hospital for Sick Children, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada.
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15
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Extracellular matrix for repair of type IV laryngotracheo-esophageal cleft. Int J Pediatr Otorhinolaryngol 2015; 79:2484-6. [PMID: 26616544 DOI: 10.1016/j.ijporl.2015.10.058] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 10/30/2015] [Accepted: 10/31/2015] [Indexed: 11/23/2022]
Abstract
Type IV laryngotracheo-esophageal cleft (LTEC) extending to the level of the carina presents unique challenges to operative repair, particularly with respect to soft tissue durability. This is the first report of CorMatrix(®) extra-cellular matrix (ECM) material use as an interposition graft in a four-layered LTEC repair. At day seven post-operatively, there was epithelialization along the surface of the trachea. At 3 months, she was stable for tracheotomy. At 6 months, the posterior wall resembled completely native tissue. CorMatrix(®) ECM(®) use intra-operatively and post-operative outcome were both highly satisfactory. No adverse reaction was seen in this case through 12-month follow up.
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16
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Griffith CL, Liversedge TFG. Laryngeal clefts. BJA Educ 2015. [DOI: 10.1093/bjaed/mku046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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18
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Propst EJ. Repair of short type IV laryngotracheoesophageal cleft using long, tapered, engaging graft without need for tracheotomy. Laryngoscope 2015; 126:1006-8. [DOI: 10.1002/lary.25472] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 05/25/2015] [Accepted: 06/08/2015] [Indexed: 11/12/2022]
Affiliation(s)
- Evan J. Propst
- Department of Otolaryngology-Head and Neck Surgery; Hospital for Sick Children; Toronto Ontario Canada
- Department of Otolaryngology-Head and Neck Surgery; University of Toronto; Toronto Ontario Canada
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19
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Ryan DP, Doody DP. Management of congenital tracheal anomalies and laryngotracheoesophageal clefts. Semin Pediatr Surg 2014; 23:257-60. [PMID: 25459009 DOI: 10.1053/j.sempedsurg.2014.09.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Congenital obstructions and anomalies of the pediatric airway are rare problems that may be associated with mild symptoms or critical stenoses that may be life threatening in the first few days of life. This review provides an overview of the embryologic development of the airway, different congenital anomalies associated with airway development, and surgical correction that may be associated with good long-term outcome.
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Affiliation(s)
- Daniel P Ryan
- Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, Massachusetts 02114.
| | - Daniel P Doody
- Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, Massachusetts 02114
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20
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Johnston DR, Watters K, Ferrari LR, Rahbar R. Laryngeal cleft: evaluation and management. Int J Pediatr Otorhinolaryngol 2014; 78:905-11. [PMID: 24735606 DOI: 10.1016/j.ijporl.2014.03.015] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Revised: 03/14/2014] [Accepted: 03/15/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVES Review the latest diagnostic and treatment modalities for laryngeal and laryngotracheoesophageal clefts as they can be a major cause of respiratory and feeding morbidity in the infant and pediatric population. METHODS Literature review of published reports. RESULTS The presentation of laryngeal cleft usually involves respiratory symptoms, such as stridor, chronic cough, aspiration, and recurrent respiratory infections. Clefts of the larynx and trachea/esophagus can occur in isolation, as part of a syndrome (Opitz-Frias, VATER/VACTERL, Pallister Hall, CHARGE), or with other associated malformations (gastrointestinal, genitourinary, cardiac, craniofacial). This publication reviews the presenting signs/symptoms, diagnostic options, prognosis, and treatment considerations based on over a decade of experience of the senior author with laryngeal clefts. CONCLUSIONS Type I laryngeal clefts can be managed medically or surgically depending on the degree of morbidity. Types II, III, and IV require endoscopic or open surgery to avoid chronic respiratory and feeding complications.
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Affiliation(s)
- Douglas R Johnston
- Division of Otolaryngology, Nemours Alfred I. DuPont Hospital for Children, Wilmington, DE, United States.
| | - Karen Watters
- Department of Pediatric Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, MA, United States; Department of Otology and Laryngology, Harvard Medical School, Boston, MA, United States
| | - Lynne R Ferrari
- Department of Anesthesiology, Boston Children's Hospital, Boston, MA, United States
| | - Reza Rahbar
- Department of Pediatric Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, MA, United States; Department of Otology and Laryngology, Harvard Medical School, Boston, MA, United States
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21
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Leishman C, Monnier P, Jaquet Y. Endoscopic repair of laryngotracheoesophageal clefts: experience in 17 cases. Int J Pediatr Otorhinolaryngol 2014; 78:227-31. [PMID: 24332198 DOI: 10.1016/j.ijporl.2013.10.068] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Revised: 10/28/2013] [Accepted: 10/29/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To review the presentation and evaluation of laryngotracheoesophageal clefts as well as their treatment modalities, especially endoscopic closure. STUDY DESIGN retrospective case series. METHODS All patients treated for laryngotracheoesophageal clefts in our clinic during the last 15 years were included. Analysis of preoperative data, surgical success and functional outcome was performed. RESULTS A total of 18 patients were included in our study. Cleft distribution was: type I (n=1), type II (n=3), type IIIa (n=5), type IIIb (n=8) and type IVa (n=1). All clefts were closed endoscopically by CO2 laser repair except for two patients who benfited from open surgery (one type I, one type IIIb). 7 of our 18 patients (39%) experienced a complication necessitating reoperation. Surgical treatment of LTEC allowed cessation of feeding tube assistance and artificial ventilation in 47% and 42% of patients respectively. CONCLUSION Surgical treatement of laryngotracheoesophageal clefts remains a complex procedure with a high rate of morbidity for high grade clefts. Post-surgical difficulties in feeding and breathing are associated with concomitant congenital anomalies. Endoscopic repair is a successful technique for treating up to grade IIIa laryngeal clefts. Further investigation is needed to assess the best approach for treating longer clefts.
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Affiliation(s)
- Crispin Leishman
- Clinic of Otorhinolaryngology and Head and Neck Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.
| | - Philippe Monnier
- Clinic of Otorhinolaryngology and Head and Neck Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Yves Jaquet
- Clinic of Otorhinolaryngology and Head and Neck Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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22
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Serio P, Leone R, Fainardi V, Baggi R, Murzi B, Noccioli B, Arcieri L, Mirabile L. The role of endoscopy in the treatment of IV type laryngotracheal cleft complications after surgical repair. Int J Pediatr Otorhinolaryngol 2014; 78:377-80. [PMID: 24332666 DOI: 10.1016/j.ijporl.2013.11.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Revised: 11/15/2013] [Accepted: 11/17/2013] [Indexed: 11/16/2022]
Abstract
Laryngotracheal cleft (LTC) is a rare congenital anomaly. Severe forms of LTC are usually treated surgically using extracorporeal circulation. Despite tremendous improvement of surgical techniques, postoperative complications are still frequent. We report a comprehensive description of an endoscopic approach to diagnosis, surgical repair and endoscopic treatment of complications after correction in a type IV LTC.
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Affiliation(s)
- P Serio
- Respiratory Endoscopy Unit, Department of Paediatric Anesthesia and Intensive Care, Meyer Children Hospital, Florence, Italy.
| | - R Leone
- Respiratory Endoscopy Unit, Department of Paediatric Anesthesia and Intensive Care, Meyer Children Hospital, Florence, Italy; Department of Anesthesia and Intensive Care, Ospedale Riuniti di Foggia, Foggia, Italy
| | - V Fainardi
- Respiratory Endoscopy Unit, Department of Paediatric Anesthesia and Intensive Care, Meyer Children Hospital, Florence, Italy; Department of Paediatrics, Parma Children Hospital, Parma, Italy
| | - R Baggi
- Respiratory Endoscopy Unit, Department of Paediatric Anesthesia and Intensive Care, Meyer Children Hospital, Florence, Italy
| | - B Murzi
- Pediatric Cardiac Surgery, Heart Hospital, G. Monasterio Tuscany Foundation, Massa, Italy
| | - B Noccioli
- Neonatal Surgery Unit, Feto-Neonatal Department, Meyer Children Hospital, Florence, Italy
| | - L Arcieri
- Pediatric Cardiac Surgery, Heart Hospital, G. Monasterio Tuscany Foundation, Massa, Italy
| | - L Mirabile
- Respiratory Endoscopy Unit, Department of Paediatric Anesthesia and Intensive Care, Meyer Children Hospital, Florence, Italy
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Yasui Y, Kohno M, Shironomae T, Kuwahara T, Takahashi S, Oshikiri T, Tsuji H. Laryngotracheal separation for a type 4 laryngotracheoesophageal cleft with multiple significant malformations. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2013. [DOI: 10.1016/j.epsc.2013.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Propst EJ, Ida JB, Rutter MJ. Repair of long type IV posterior laryngeal cleft through a cervical approach using cricotracheal separation. Laryngoscope 2013; 123:801-4. [DOI: 10.1002/lary.23660] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2012] [Indexed: 11/07/2022]
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Ongkasuwan J. In Search of the Elusive Laryngotracheal Cleft. PEDIATRIC ALLERGY, IMMUNOLOGY, AND PULMONOLOGY 2012; 25:143-149. [DOI: 10.1089/ped.2012.0154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Julina Ongkasuwan
- Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
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Leboulanger N, Garabédian EN. Laryngo-tracheo-oesophageal clefts. Orphanet J Rare Dis 2011; 6:81. [PMID: 22151899 PMCID: PMC3261097 DOI: 10.1186/1750-1172-6-81] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2010] [Accepted: 12/07/2011] [Indexed: 01/09/2023] Open
Abstract
A laryngo-tracheo-esophageal cleft (LC) is a congenital malformation characterized by an abnormal, posterior, sagittal communication between the larynx and the pharynx, possibly extending downward between the trachea and the esophagus. The estimated annual incidence of LC is 1/10,000 to 1/20,000 live births, accounting for 0.2% to 1.5% of congenital malformations of the larynx. These incidence rates may however be underestimated due to difficulty in diagnosing minor forms and a high mortality rate in severe forms. A slightly higher incidence has been reported in boys than in girls. No specific geographic distribution has been found. Depending on the severity of the malformation, patients may present with stridor, hoarse cry, swallowing difficulties, aspirations, cough, dyspnea and cyanosis through to early respiratory distress. Five types of laryngo-tracheo-esophageal cleft have been described based on the downward extension of the cleft, which typically correlates with the severity of symptoms: Type 0 laryngo-tracheo-esophageal cleft to Type 4 laryngo-tracheo-esophageal cleft. LC is often associated with other congenital abnormalities/anomalies (16% to 68%), mainly involving the gastro-intestinal tract, which include laryngomalacia, tracheo-bronchial dyskinesia, tracheo-bronchomalacia (mostly in types 3 and 4), and gastro-esophageal reflux disease (GERD). The syndromes most frequently associated with an LC are Opitz/BBB syndrome, Pallister Hall syndrome, VACTERL/VATER association, and CHARGE syndrome. Laryngeal clefts result from failure of fusion of the posterior cricoid lamina and abnormal development of the tracheo-esophageal septum. The causes of the embryological developmental anomalies leading to LC are not known but are thought to be multifactorial. LC appears to be mostly sporadic although some familial cases with suspected autosomal dominant transmission have been reported. The age of diagnosis depends mainly on the severity of the clinical symptoms and therefore on the extent of the LC. Diagnosis is made either based on clinical manifestations or on investigations, such as endoscopy, X-ray, CT scan, performed for other conditions. Differential diagnoses include tracheo-bronchial fistula, gastro-esophageal reflux disease and neurological swallowing disorders, as well as laryngomalacia and laryngeal palsy. Prenatal diagnosis of LC has never been reported, although associated anomalies may be detected on fetal ultrasonography. Once the cleft is diagnosed, it is essential to determine its length to orient the management and treatment approach. Management involves maintenance of satisfactory ventilation, prevention of secondary pulmonary complications as a result of repeated aspirations, and adequate feeding. Endotracheal intubation may be required for respiratory distress in severe cases. Treatment requires endoscopic or external surgery to close the cleft. Surgery should be performed as early as possible to avoid complications related to aspiration and gastric reflux, except in type 0 and type 1 cases in which conservative measures must first be attempted. The prognosis is variable depending on the severity of the LC and associated malformations. Early diagnosis and appropriate treatment and management help to reduce mortality and morbidity.
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Affiliation(s)
- Nicolas Leboulanger
- Paediatric Otolaryngology-Head and Neck surgery Department, UPMC-Paris VI University, Armand-Trousseau Children's Hospital, Paris, France.
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Thiel G, Clement WA, Kubba H. The management of laryngeal clefts. Int J Pediatr Otorhinolaryngol 2011; 75:1525-8. [PMID: 21937125 DOI: 10.1016/j.ijporl.2011.08.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2011] [Revised: 08/24/2011] [Accepted: 08/25/2011] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To review the clinical presentation and management of all infants and children presenting with laryngeal clefts to a tertiary pediatric ENT centre and to identify changes in practice over time. PATIENTS AND METHODS A retrospective case note review of the management of all infants and children with a diagnosis of a laryngeal cleft identified in our Department between 01/11/2003 and 31/12/2010. RESULTS Twelve children with laryngeal clefts were identified. Six clefts were grade 1, five grade 2 and one grade 3b. All grade 1 clefts were managed conservatively. Of the grade 2 clefts, four required surgery with one being managed conservatively. Two were repaired using an open technique and two using an endoscopic technique. The grade 3b cleft was repaired endoscopically. Two cleft repairs broke down post-operatively requiring further surgery. CONCLUSIONS Conservative management remains the management of choice for lower grade clefts. Where a laryngeal cleft requires repair there has been a trend towards the endoscopic over open technique, even of more extensive clefts.
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Affiliation(s)
- Gundula Thiel
- Department of Paediatric Otolaryngology - Head and Neck Surgery, Royal Hospital for Sick Children, Yorkhill, Glasgow, United Kingdom.
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Owusu JA, Sidman JD, Anderson GF. Type IV laryngotracheoesophageal cleft: report of long-term survivor successfully decannulated. Int J Pediatr Otorhinolaryngol 2011; 75:1207-9. [PMID: 21752479 DOI: 10.1016/j.ijporl.2011.06.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2011] [Revised: 06/12/2011] [Accepted: 06/16/2011] [Indexed: 10/18/2022]
Abstract
Laryngotracheoesophageal cleft (LTEC) is a rare congenital anomaly that results from failed posterior fusion of the cricoid cartilage and incomplete development of the tracheoesophageal septum. LTEC presents with increased secretions, respiratory distress, aspiration and recurrent pulmonary infections. The severity of presenting symptoms is dependent on the type of cleft. LTEC is most commonly classified into four types (I, II, III and IV) based on the inferior extent of the cleft. Types III and IV LTEC are associated with high morbidity and mortality and require timely diagnosis and repair for survival. Most patients who survive repair of Type IV LTEC have long-term tracheotomy dependency with minimal chance of decannulation. We report on a case of a long-term survivor of Type IV who has been safely decannulated.
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Affiliation(s)
- James A Owusu
- Department of Otolaryngology, University of Minnesota, 420 Delaware St., Minneapolis, MN 55455, United States.
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Geller K, Kim Y, Koempel J, Anderson KD. Surgical management of type III and IV laryngotracheoesophageal clefts: the three-layered approach. Int J Pediatr Otorhinolaryngol 2010; 74:652-7. [PMID: 20416955 DOI: 10.1016/j.ijporl.2010.03.013] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2009] [Revised: 03/03/2010] [Accepted: 03/08/2010] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The objective of this paper is to present our surgical experience with a cohort of four infants with laryngotracheoesophageal cleft (LTEC) in order to highlight our early failures and complications and to propose a comprehensive, three-layered approach in treating stages III and IV LTEC. METHOD An IRB approved, retrospective chart review was carried out of a cohort of four cases occurring within a 2-year period of time. RESULTS All patients had other significant anomalies, and the mortality rate was high: 75%. After our initial failures and difficulties with recurrent fistulas, tracheomalacia and tracheotomy dependence, we were able to achieve a successful outcome of a functional separation of the airway and the digestive tract without a tracheotomy in our last two patients. Unfortunately, both these patients died from factors not directly associated with the LTEC so long-term follow up was not possible. We now have one survivor, our second case, who is tracheotomy dependent. CONCLUSION Laryngotracheoesophageal clefts are rare congenital anomalies with high morbidity and mortality despite various forms of surgical repair. Fistulas, tracheostomy dependence, tracheomalacia, and chronic lung disease secondary to aspiration are frequent problems following LTEC repairs. We advocate an anterior approach to the cleft repair, a three-layered closure of the cleft to include an interpositional muscular flap, and a physiologic repair of the posterior larynx with a standard cartilage graft technique used in laryngotracheal reconstruction.
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Affiliation(s)
- Kenneth Geller
- Division of Otolaryngology/Head and Neck Surgery, University of Southern California, Keck School of Medicine, Children's Hospital of Los Angeles, Los Angeles, CA 90027, United States.
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Pezzettigotta SM, Leboulanger N, Roger G, Denoyelle F, Garabédian EN. Laryngeal Cleft. Otolaryngol Clin North Am 2008; 41:913-33, ix. [DOI: 10.1016/j.otc.2008.04.010] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Russell P, Chambers N, du Plessis J, Vijayasekeran S. Emergency use of a size 1 laryngeal mask airway in a ventilated neonate with an undiagnosed type IV laryngotracheo-oesophageal cleft. Paediatr Anaesth 2008; 18:658-62. [PMID: 18482241 DOI: 10.1111/j.1460-9592.2008.02584.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The perioperative management of a neonate with a type IV laryngotracheo-oesophageal cleft and exomphalos major is described. Following an otherwise uncomplicated exomphalos repair, this baby became increasingly and inexplicably difficult to ventilate through an endotracheal tube. The emergency use of a laryngeal mask airway as a rescue maneuver allowed positive pressure ventilation, and subsequent diagnosis of the airway abnormality. The difficulties in management of the two co-existing conditions are discussed.
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Affiliation(s)
- Philip Russell
- Department of Anaesthesia, Princess Margaret Hospital for Children, Perth, WA, Australia.
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Bibliography. Current world literature. Laryngology and bronchoesophagology. Curr Opin Otolaryngol Head Neck Surg 2007; 15:417-24. [PMID: 17986882 DOI: 10.1097/moo.0b013e3282f3532f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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