Type 1 Laryngeal Cleft

Considerations

• • Rare

  • Difficult to diagnose

    • Symptoms and signs revolve around aspiration

    • Gold standard = Suspension microlaryngobronchoscopy

      • Posterior palpation is key

      • 2003: Diagnosis and management of type 1 laryngeal cleft - A posterior cleft can be identified by using a forceps in each hand to distract the right and left arytenoids and identify the presence or absence of the interarytenoid muscle. A type 1 cleft is the absence of the interarytenoid muscle.

      • 2014: Type 1 laryngeal cleft: A multidimensional management algorithm - May use a suction probe to palpate

  • Classification

    • 1985, Evans: Type 1, 2, and 3 

    • 1989, Benjamin and Inglis: Type 1, 2, 3, and 4

  • Management 

    • Conservative measures 

      • Prevent GERD

      • Avoid thin liquids

      • Maneuvers during feeding to limit aspiration 

  • Benjamin and Inglis classification

    • Type 1 - observation, endoscopic repair as needed

    • Type 2-3 - cervical approach

    • Type 4 - combined cervical approach and lateral thoracotomy

Preparation

• • Spontaneous breathing vs ETT

Procedure

• Endoscopic approach

  • Suspension microlaryngobronchoscopy

    • Lindholm laryngoscope

  • A mucosal margin of the cleft is excised

    • 2006: The presentation and management of laryngeal cleft: A 10-year experience

      • Carbon dioxide laser at a setting of 3 W at 0.3-second intermittent mode was used to denude the mucosal margin of the cleft. It is of paramount importance to completely remove the mucosa at the apex of the cleft to prevent persistence of the fistula at the lower end of the repair

  • Repair is then performed in two layers with interrupted absorbable sutures (6′0 vicryl poly) on a spatulated needle

    • 2006: The presentation and management of laryngeal cleft: A 10-year experience

      • • Absorbable interrupted sutures (4-0 Vicryl) are used to close the cleft. The first suture is the most important and must be placed at the most inferior extent of the cleft. We generally place 3 to 4 sutures, depending on the extent of the cleft

    • Place NGT

Post-op

• Close airway observations

• NGT feeding, broad-spectrum antibiotics and gastric acid suppressants for 5 days

• Repeat suspension microlaryngobronchoscopy in 4 weeks 

High-Yield

Links

• eMedicine: Congenital Malformations of the Esophagus - Laryngotracheoesophageal Cleft

• Wikipedia: Laryngeal Cleft

  • Laryngeal Cleft PowerPoint from National Taiwan University Hospital - more clinical and surgical details