Surgical treatment of laryngomalacia

Strategies for CO2 Laser Use in Laryngeal Microsurgery: A Systematic Review

OBJECTIVE

We aim to systematically review the literature addressing perioperative practices for optimal use of the CO2 laser in laryngeal transoral laser microsurgery (TOLMS), with a focus on safety.

DATA SOURCES

A systematic review of publications indexed in Medline, Embase, and EBM reviews-Cochrane Central Register of Controlled Trials which evaluated perioperative strategies for the use of CO2 laser in laryngeal TOLMS was conducted.

REVIEW METHODS

Records obtained from the search strategy were assessed for eligibility in a 2-step process by 2 independent researchers using the Covidence software.

RESULTS

Among 2143 identified records, 103 were included in this study. The majority of studies (n = 25) focused on the use of the CO2 laser in oncologic resection, while 20 addressed the treatment of vocal cord paralysis, 16 discussed the treatment of pediatric or congenital pathologies, 11 detailed the management of benign lesions, and 31 studies tackled other surgical indications. Strategies for safe CO2 TOLMS were highly heterogeneous across studies and included preoperative measures (ie, related to the environment, staff preparation, patient protection, and ventilation), intraoperative precautions (ie, protection of nontarget structures, technical considerations, topical and systemic medications), and postoperative strategies (ie, related to airway protection, oral intake, vocal rest, hospitalization duration, drug regimen, and consultant follow-up).

CONCLUSION

The results provided in this study can be used as a framework to guide the creation of laser safety protocols across institutions, guide quality improvement initiatives, the development of simulation training activities, and as a tool to facilitate resident teaching and skill assessment.

Success of supraglottoplasty for severe laryngomalacia: the experience from Northeastern Ontario, Canada

OBJECTIVES

To review the outcomes of supraglottoplasty performed in children with severe laryngomalacia at a pediatric university teaching hospital and to determine if these outcomes are influenced by gender, age at time of supraglottoplasty, or medical comorbidities.

METHODS

Retrospective chart review of children who underwent supraglottoplasty for severe laryngomalacia between 2001 and 2010 at the Children's Hospital of Eastern Ontario in Ottawa, Canada. Statistical significance was obtained using 2-tailed Fisher's exact test. The outcome measures were resolution of laryngomalacia symptoms or persistence of laryngomalacia symptoms with or without additional surgery.

RESULTS

Among 26 post-primary supraglottoplasty patients, 46.2% had resolution and 53.8% had persistence, including 19.2% with partial improvement and 34.6% requiring revision supraglottoplasty and/or tracheostomy. Resolution was present in 35.7% of males and 58.3% of females (p = 0.43); in 33.3% of all patients ≤2 months old and 52.9% of all patients >2 months old (p = 0.43); and in 50.0% of non-comorbid patients ≤2 months old and 80.0% of non-comorbid patients >2 months old (p = 0.52). 71.4% of persistence cases were found in comorbid patients. 83.3% of comorbid patients had persistence, compared to 28.6% of non-comorbid patients (p=0.008). Of the 3 patients with overlapping comorbid categories, 2 required at least 2 revision supraglottoplasties and ultimately required a tracheostomy.

CONCLUSIONS

Persistence of laryngomalacia symptoms post-primary supraglottoplasty was not associated with gender or age at time of surgery, and was more commonly found in children with comorbidities. Patients with coexisting medical conditions appear to require more aggressive surgical management, beyond one revision supraglottoplasty.