A novel technique for unilateral supraglottoplasty

Disposition to pediatric intensive care unit post supraglottoplasty repair: a systematic review

BACKGROUND

Patients undergoing supraglottoplasty are often routinely admitted post-operatively to the pediatric intensive care unit (PICU) due to rare but potentially fatal complications such as airway compromise. A systematic review was performed to determine the rate of post-operative PICU-level respiratory support required by pediatric patients following supraglottoplasty, to identify risk factors for patients who may benefit from post-operative PICU admission and limit unnecessary use of intensivist resources.

REVIEW METHODS

Key search terms 'supraglottoplasty' OR 'supraglottoplasties' were queried on three databases: CINHAL, Medline and Embase. Inclusion criteria were pediatric patients under 18 years of age who underwent a supraglottoplasty procedure with either an admission to PICU or requirement for PICU-level respiratory support. Risk of bias was assessed by two independent reviewers using QUADAS-2. Findings were critically appraised by three independent reviewers and pooled proportions of criteria meeting PICU admission were calculated for meta-analysis.

RESULTS

Nine studies met inclusion criteria, totaling 922 patients. Age at time of surgery ranged from 19 days to 15.7 years with mean age of 5.65 months. A weighted pooled estimate suggested that 19% (95% CI 14-24%) of patients who underwent supraglottoplasty required PICU-admission. The included studies revealed several patient and surgical factors have been linked to postoperative respiratory issues requiring PICU admission, including: neurological disease, perioperative oxygen saturation < 95%, prolonged surgical time and age < 2 months.

CONCLUSIONS

This study found that the majority of supraglottoplasty patients do not require significant postoperative respiratory support and suggests that routine PICU admission of these patients may be avoided by careful patient selection. Given the wide heterogeneity of outcome measures, further studies are needed to determine the ideal PICU admission criteria following supraglottoplasty.

Pediatric laryngeal cleft repair with coblation: Functional comparison of a novel technique with traditional methods

OBJECTIVES

The traditional endoscopic techniques for surgical management of laryngeal clefts are carbon dioxide (CO2) laser or microlaryngeal instruments (cold steel). This study compares the functional efficacy and safety of coblation, or "cold" radiofrequency ablation, to traditional approaches for endoscopic laryngeal cleft repair.

METHODS

Patients who underwent endoscopic laryngeal cleft repair with CO2 laser, cold steel, or coblator at two tertiary academic centers from 2015 to 2021 were retrospectively identified. The primary outcome studied was swallowing function: pre- and postoperative swallow studies were scored according to the International Dysphagia Diet Standardization Initiative with higher scores indicating worse swallow function. Secondary outcomes included surgical complications and rates of dehiscence.

RESULTS

Of the 53 patients included, 14 underwent repair with CO2 laser, 23 with cold steel, and 16 with the coblator. Mean age at surgery was 2.2 ± 1.1 years for the laser group, 4.3 ± 4.0 years for cold steel, and 1.9 ± 1.4 years for the coblator group. In the laser group, 100% of clefts were type I; for the cold steel group, 82.6% of clefts were type I and 17.4% were type II; for the coblator group, 93.8% of clefts were type I and 6.3% were type II. Pre- and postoperative swallow study scores were 6.3 ± 2.8 and 4.3 ± 3.2, respectively, (p = 0.001) for the laser group, 6.9 ± 2.8 and 5.3 ± 3.1 (p = 0.071) for the cold steel group, and 7.5 ± 1.5 and 4.0 ± 2.9 (p < 0.001) for the coblator group. Mean change in swallow study scores were similar across the three groups (p = 0.212). No patients experienced postoperative dehiscence at the surgical site or complications; no revisions were required.

CONCLUSIONS

Cleft repair with the novel coblation technique showed significant improvements in swallow study scores without any occurrences of postoperative dehiscence or revisions. Coblation is a safe and efficacious approach for laryngeal cleft repair.

Coblation supraglottoplasty: a ten-year experience in a tertiary referral hospital

PURPOSE

The present study aims to review the outcomes of coblation supraglottoplasty performed for children with different types of laryngomalacia, and we discuss the factors affecting these outcomes.

METHODS

We retrospectively reviewed the medical records of laryngomalacia patients admitted to the Otorhinolaryngology Department, Mansoura University, from 2010 to 2020. We examined the patient's demography, symptoms, comorbidities, type of laryngomalacia, oxygen saturation, and final outcomes.

RESULTS

Our study included 235 patients; 122 patients responded to medical therapy, while 113 underwent surgical management. There is a significant relation between the types and therapy they underwent (p ≤ 0.001). Larger percentage within type I underwent medical therapy. There is a statistically significant difference between the studied groups regarding age at surgery. On pairwise comparison, patients with type II had the lowest age significantly at the surgery when compared with each other individual group (p ≤ 0.001). On multivariate regression analysis, the presence of comorbid congenital heart disease, neurological comorbidities significantly increased the risk of failure of surgical intervention by 17.32 and 5.803 folds, respectively.

CONCLUSIONS

Coblation supraglottoplasty is effective and safe to treat severe laryngomalacia. Different morphological types of laryngomalacia require slight surgical variations of coblation supraglottoplasty. The presence of comorbid congenital heart disease, neurological comorbidities significantly increased the risk of failure of surgical intervention.

One and half coblation supraglottoplasty: A novel technique for management of type II laryngomalacia

OBJECTIVES

Endoscopic supraglottoplasty is the mainstay surgical procedure in treatment of laryngomalacia. Various instruments have been used with coblation recently gaining widespread attention. Regarding the technique used, cutting the aryepiglottic folds is associated with rapid improvement but carries risk of restenosis while outer scar contracture method has delayed but established result. Therefore, this study was conducted to introduce a modified coblation supraglottoplasty technique gathering both benefits and evaluate its results and effectiveness.

METHODS

Retrospective study included patients diagnosed with type II laryngomalacia was conducted. Supraglottoplasty was done by "one and half coblation supraglottoplasty" technique which involves cutting of one aryepiglottic fold while the other one is laterally coagulated. Patients' basic and clinical data were assessed. Outcome measures included assessment of inspiratory stridor, failure to thrive, choking, cyanosis, lowest oxygen saturation levels and weight gain.

RESULTS

Seventeen patients were included in this study with a mean age of 3.71 ± 1.1 months. Significant statistical improvement was reached regarding stridor, failure to thrive and cyanosis. Also, minimal oxygen saturation and weight gain were significantly improved. None of the cases needed tracheostomy and no major postoperative complications occurred.

CONCLUSION

We conclude that "one and half coblation supraglottoplasty" is an effective and safe treatment for type II laryngomalacia with satisfactory outcomes.

LEVEL OF EVIDENCE

IV.

Efficacy and toxicities of low-temperature plasma radiofrequency ablation for the treatment of laryngomalacia in neonates and infants: a prospective randomized controlled trial

Background

Laryngomalacia is the most common cause of stridor in neonates and infants, and supraglottoplasty is the mainstay of surgical treatment. Although low-temperature plasma radiofrequency ablation (LTP-RFA) using coblation technology has been used for treating laryngomalacia, it is still lack of high-quality clinical evidence. Therefore, we conduct this prospective randomized study to clearly define the role of LTP-RFA for the treatment of laryngomalacia in neonates and infants.

Methods

Between Jan 2017 and Dec 2019, a total of 89 children with laryngomalacia were included for analysis. All patients were initially stratified according to the severity of laryngomalacia. Patients with severe laryngomalacia were randomly assigned to receive LTP-RFA or traditionally surgical supraglottoplasty, while patients with moderate laryngomalacia were assigned to LTP-RFA or observation. The primary end point was the efficacy and toxicities of LTP-RFA by assessing the changes of clinical score and visual analogue scale (VAS) symptom score. The total score was the combination of clinical score with VAS score.

Results

Of the 89 children, 40 children presented with severe laryngomalacia, and the remaining 49 children were diagnosed as moderate laryngomalacia. The median age was 68 days (range, 19 to 337 days). For children with severe laryngomalacia, our results showed that LTP-RFA treatment significantly reduced the operative time (5.55±1.66 vs. 18.7±5.31 min, P<0.001), length of hospital stay (6.71±1.15 vs. 7.95±1.55 days, P=0.008) and the amount of intraoperative hemorrhage (1.71±1.79 vs. 4.90±1.82, P<0.001) when compared to traditionally surgical supraglottoplasty, while the treatment efficacy was comparable between LTP-RFA and traditionally surgical supraglottoplasty in terms of changed total score (P=0.322), changed clinical score (P=0.135) and changed VAS symptom score (P=0.559). Additionally, for children with moderate laryngomalacia, LTP-RFA treatment significantly improved the symptom evaluated by total score (P<0.001), clinical score (P<0.001) and VAS symptom score (P<0.001) in comparison with the observation group. Post-operative pneumonia was observed in 10 patients. No surgical related death was reported.

Conclusions

The present study indicated that LTP-RFA was an effective treatment option for both severe and moderate laryngomalacia in neonates and infants with a low intraoperative complication. Long-term outcomes of LTP-RFA for laryngomalacia would be reported in further studies.

Coagulation of the lateral surface of aryepiglottic folds as an alternative to aryepiglottic fold release in management of type 2 laryngomalacia

OBJECTIVE

Endoscopic supraglottoplasty is the procedure of choice in treatment of laryngomalacia with CO2 laser and cold steel being the most common instruments used with excellent results. However, bleeding, supraglottic stenosis and aspiration may occur leading to serious complications. Using coblation in management of laryngomalacia was found to be beneficial. Therefore, we conducted this study to evaluate the outcome of supraglottoplasty done by coagulation using coblation of the lateral surface of aryepiglottic folds as an alternative technique to aryepiglottic fold release in management of type 2 laryngomalacia.

METHODS

Retrospective study was conducted at Mansoura University Hospitals; Egypt from November 2017 to March 2018 included patients diagnosed with severe type 2 laryngomalacia. Supraglottoplasty was done by using coblator applied to the lateral surface of aryepiglottic folds allowing for lateral scarring thus widening the airway, preventing supraglottic collapse and avoiding re-stenosis. Outcome measures included assessment of presence or absence of the following symptoms preoperatively and postoperatively: inspiratory stridor, failure to thrive, choking and cyanosis. Preoperative and postoperative lowest oxygen saturation levels, weight-by-age percentile, and need for tracheostomy were assessed.

RESULTS

Nine patients were included in this study with a mean age of 3.78 ± 1.20 months (range 2-6 months). Overall success rate was 89%. The most significantly improved symptom was stridor (p-value 0.008). Significant improvement in lowest oxygen saturation levels (from 89.11 ± 3.06% pre-operatively to 96.44 ± 3.50% post-operatively) and weight gain (from 4288.9 ± 643.1 gm. preoperatively to 5505.55 ± 1017.4 gm. 1 month postoperatively) was achieved. No detected re-stenosis on follow up and none of our cases needed tracheostomy.

CONCLUSION

Supraglottoplasty by coagulation of the lateral surface of aryepiglottic folds using coblation is an effective and safe technique and can improve airway symptoms and weight gain in patients with type 2 laryngomalacia.

Harmonic Shears in the Surgical Treatment of Laryngomalacia

Introduction Laryngomalacia (LM) is a condition that is clinically diagnosed in the pediatric period with inspiratory stridor and is caused by a congenital or acquired collapse of laryngeal suprastructures. Endoscopic supraglottoplasty is the modern gold standard surgical treatment for severe or complicated laryngomalacia. Various cold and powered surgical devices have been used to approach the aryepiglottic folds, and their advantages and drawbacks have been widely discussed. The applicability of Ultracision Harmonic shears (Ethicon Inc., NJ, US) for the sake of supraglottoplasty has not been previously advocated in the literature and is the subject of this study. Methods This was a review of the medical records of pediatric patients, with moderate to severe congenital laryngomalacia, who underwent supraglottoplasty with Harmonic at a single institution, from 2013 to 2019. Results A total of six patients underwent bilateral aryepiglottic fold division with the use of Ultracision in the study period (4 male, 2 female; mean age 7+/-9 months, age range 1m-24m). Postoperatively, all of the children were extubated and admitted to the pediatric intensive care unit (PICU) as a precaution measure. There were no early or late complications after the intervention. The postoperative endoscopic picture was evaluated in three patients (two of which for another reason). A stable laryngeal frame with no collapse or excessive scarring was observed. None of the patients required repeat surgery. Conclusion Based on the ease of surgical access, performance, surgical precision, and postoperative results, the use of Harmonic scissors appears to be a safe, practical, affordable, and easily applicable alternative for supraglottoplasty Type 2.

Unilateral vs Bilateral Supraglottoplasty: A Meta-analysis of Rates of Return to Surgery and Supraglottic Stenosis

OBJECTIVE

To perform a systematic review with meta-analysis of data to determine the rates of repeat surgery and supraglottic stenosis in unilateral versus bilateral supraglottoplasty for laryngomalacia.

DATA SOURCES

PubMed/Medline, Cochrane Central, Scopus, Google Scholar, Web of Science, and Embase.

REVIEW METHODS

Databases were searched through January 30, 2018. Studies with unilateral or bilateral supraglottoplasty techniques for laryngomalacia were included. The need for repeat (revision or completion) surgery and rates of supraglottic stenosis were primary outcomes. Data were substratified and a meta-analysis performed.

RESULTS

A total of 251 articles were reviewed, and 20 articles met inclusion criteria (1186 patients: 663 bilateral, 523 unilateral). Regarding the need to return to surgery, the rate of revision for bilateral surgery was 4.1%, compared to the revision and combined revision/completion rates for unilateral surgery which respectively were 1.1% (odds ratio [OR] 0.27; 95% CI 0.11-0.67; P = .002) and 18.0% (OR 5.16; 95% CI 3.31-8.06; P < .0001). The unilateral versus bilateral supraglottic stenosis rates were 0% versus 1.2% (P = .011).

CONCLUSION

Unilateral supraglottoplasty has a significantly higher rate of repeat surgery, mainly attributed to contralateral surgery, when compared with bilateral supraglottoplasty. There is a small but statistically significant risk of supraglottic stenosis in bilateral procedures. The benefit of a unilateral procedure should be weighed against the cost of subjecting patients to a 4-fold increased risk of repeat surgery.