Disease, Illness & ConditionsAches & PainsOral HealthInjuriesDigestive HealthEye CareWellnessChildren's HealthOlder AdultsFirst AidMental HealthHealth Care IndustryDisabilitiesAlternative MedicineReproductive Health

Supraglottoplasty Surgery for Laryngomalacia: What to Expect

Updated on July 28, 2017
leahlefler profile image

Our younger son had his first supraglottoplasty and epiglottopexy at the age of three years. He had a second surgery at the age of 5-1/2.

Surgery for Laryngomalacia

The author's son recovers from his second supraglottoplasty and epiglottopexy surgery.
The author's son recovers from his second supraglottoplasty and epiglottopexy surgery. | Source

What is a Supraglottoplasty?

A supraglottoplasty is a surgical procedure to remove the extra, floppy tissue that surrounds the voice box in children who have laryngomalacia. This tissue often blocks the airway when the child inhales, creating a squeaky sound known as stridor.

There are several types of laryngomalacia. Each type of laryngomalacia has a different area of floppy tissue. The four main types are:

  • Type 1: Mucosal tissue flops over the arytenoid cartilages.
  • Type 2: Shortened aryepiglottic folds.
  • Type 3: Collapse of the epiglottis over the vocal cords.
  • Type 4: A combination of the above types.

This surgery is sometimes coupled with a procedure called an epiglottopexy, in which the epiglottis is tacked to the base of the tongue. Children with laryngomalacia often have a long epiglottis that curls up on itself. The epiglottis (which normally protects the airway when food is swallowed) may also flop over and obstruct the airway.

Types of Laryngomalacia

The three main types of laryngomalacia, as compared to a normal glottis.
The three main types of laryngomalacia, as compared to a normal glottis. | Source

Laryngomalacia Stridor in a 5 Year Old Child

When is Surgery Performed?

In the vast majority of cases, surgery is not required for laryngomalacia. Most children will have "noisy breathing," but will grow well and maintain their oxygen saturation levels. Some children will have frequent oxygen desaturations, growth failure, or severe sleep apnea that requires surgical intervention. In severe laryngomalacia, the child's ability to develop and grow are in immediate jeopardy and surgery is performed to allow the child to grow and maintain appropriate oxygenation.

Indications for surgery include:

  • Failure to thrive
  • Low oxygen saturation levels when awake
  • Obstructive sleep apnea

Some children cannot eat well due to constant oxygen desaturations when attempting to drink from a bottle, and this causes failure to thrive. Others have severe gastroesophageal reflux disease (GERD) that also causes feeding difficulties. The GERD may be silent, so the child does not necessarily vomit or have obvious symptoms of reflux - GERD often worsens laryngomalacia symptoms by inflaming the floppy tissue around the vocal cords. Likewise, the laryngomalacia can worsen the GERD symptoms, as the child creates a "vacuum" effect when trying to breathe against the obstruction in the airway. This creates a negative pressure in the esophagus, which can draw up stomach contents into the esophagus. GERD and laryngomalacia often coexist. Relieving the airway obstruction may help the child to thrive, though the reflux will often persist after the laryngomalacia has been improved via surgery.

Some infants and children have an obstruction severe enough to cause significant oxygen desaturations, even when awake, These children have daytime apneas and may turn blue. If the child has significant oxygen desaturations, surgery may be indicated.

Sleep apnea is another reason for surgery: when children sleep, their airway relaxes. For many children with laryngomalacia, this causes a complete obstruction of the airway. The child must wake up to take another breath. Untreated sleep apnea causes developmental and physical growth problems. If severe enough, the child may develop heart problems, high blood pressure, and high carbon dioxide levels that cause problems with the autonomic breathing process (the body actually relies on carbon dioxide levels to "know" when to take a breath - high CO2 levels interfere with this process).

How is the Surgery Performed?

There are two primary methods ENT surgeons use to resect the redundant tissue: some surgeons use "cold steel" (microscissors) and others use a CO2 laser. The child is asleep for the entire procedure. The excess tissue is removed and, if necessary, the epiglottis is tacked to the base of the tongue to prevent it from flopping over the child's vocal cords.

Most children are able to breathe room air following the procedure. Typically, the child will be monitored overnight in the hospital to ensure there is no airway swelling.

In some cases, the child will be intubated and kept on a ventilator for a period of time following surgery. If this occurs, the child will be placed in a pediatric intensive care unit (PICU). Once the breathing tube has been removed, the child will be monitored for at least 24 hours to ensure there are no breathing problems following the surgery.

Hospital Stay Poll

How long was your child in the hospital after having a supraglottoplasty?

See results

Recovery from a Supraglottoplasty

Pain from the surgery typically lasts for about 1 week, though the recovery may be longer for children who also had their lingual tonsils shaved. Pain medication is often prescribed by the surgeon and should be used as instructed.

Steroids and antibiotics are also prescribed for most supraglottoplasties. The steroids prevent the airway from swelling, and the antibiotics prevent infection.

Children who were not previously on a proton pump inhibitor (PPI) for acid reflux may be placed on this medication for the duration of the recovery period. If acidic reflux from the stomach irritates the surgical area, the tissues may become floppy again and render the surgery ineffective.

Some coughing and spluttering may be observed when the child drinks thin liquids. If necessary, a thickener may be used (under the direction of the supervising physician). Many children with laryngomalacia have problems with aspiration or choking prior to the procedure, and may continue to have problems after this procedure. If aspiration or choking are observed, they should be reported immediately so appropriate medical intervention (via thickeners or feeding therapy) may be initiated.

Supraglottoplasty Effectiveness Poll

Did the supraglottoplasty surgery relieve your child's laryngomalacia symptoms?

See results

Supraglottoplasty: Personal Experiences

Click thumbnail to view full-size
Our son's first supraglottoplasty in 2010: he was breathing room air and was released from the hospital 2 days after surgery. After our son's first supraglottoplasty, at age 3: recovering at home.The author's son was intubated for 48 hours following his revision supraglottoplasty and epiglottopexy (second surgery for laryngomalacia).The tube was removed after 2 days and our son was able to breathe room air. He went home 24 hours later.The author's 5 year old son, 4 days after his revision supraglottoplasty. Feeling tired and weak, but improving every day.
Our son's first supraglottoplasty in 2010: he was breathing room air and was released from the hospital 2 days after surgery.
Our son's first supraglottoplasty in 2010: he was breathing room air and was released from the hospital 2 days after surgery. | Source
After our son's first supraglottoplasty, at age 3: recovering at home.
After our son's first supraglottoplasty, at age 3: recovering at home. | Source
The author's son was intubated for 48 hours following his revision supraglottoplasty and epiglottopexy (second surgery for laryngomalacia).
The author's son was intubated for 48 hours following his revision supraglottoplasty and epiglottopexy (second surgery for laryngomalacia). | Source
The tube was removed after 2 days and our son was able to breathe room air. He went home 24 hours later.
The tube was removed after 2 days and our son was able to breathe room air. He went home 24 hours later. | Source
The author's 5 year old son, 4 days after his revision supraglottoplasty. Feeling tired and weak, but improving every day.
The author's 5 year old son, 4 days after his revision supraglottoplasty. Feeling tired and weak, but improving every day. | Source

Our Personal Experiences with Supraglottoplasties

Our family has two children with severe laryngomalacia and obstructive sleep apnea. Our younger son had his first supraglottoplasty and epiglottopexy at the age of three years.

His first supraglottoplasty was uncomplicated. The surgery took about 90 minutes to complete and we were taken to the pediatric intensive care unit once he was awake and settled. He was breathing room air and did not need to be intubated. He was upset and uncomfortable, and wanted a drink. Unfortunately, all food and liquids were prohibited for the first 24 hours after surgery. This was a difficult and miserable period of time. He was kept on intravenous fluids and given medications via the I.V. for the first day. He had no airway swelling, and he was allowed to eat and drink the following morning.

Eating and drinking were painful for him. The pain was intensified due to having his lingual tonsils shaved at the time of this procedure. The lingual tonsils are located lower down in the airway and can contribute to sleep apnea for some children. He was finally able to eat and drink, though he was quite cranky. He was released from the intensive care unit the following morning, with a total stay of 48 hours in the hospital.

Unfortunately, his supraglottoplasty failed and his stridor returned within 6 weeks. Impedance probes performed while he was on his anti-reflux medication demonstrated that his acid reflux medication was not effective. Despite being on high doses of a PPI (Nexium) and an H2 blocker (Zantac), his reflux could not be controlled. He had a Nissen Fundoplication to prevent the reflux from irritating his airway at the age of 4 1/2. He was also placed on continuous positive airway pressure therapy (C-Pap) to help control the sleep apnea.

At the age of 5 years, he lost weight and was considered failure to thrive. The pressures on his C-Pap machine had to be increased, and he often stridored over the C-Pap machine. The increasing apnea and weight loss led to two interventions: he began receiving tube feedings at the age of 5 years to help with weight gain, and another supraglottoplasty was planned.

A follow-up bronchoscopy and microlaryngoscopy demonstrated that his epiglottis was flopping over his voice box once again. The tissue surrounding his arytenoid folds was also floppy. A second supralgottoplasty was performed at the age of 5 1/2.

The revision supraglottoplasty was more intensive than the first surgery. Our son was left intubated and on a ventilator for 48 hours following surgery. His epiglottis was tacked up again and the floppy tissue was removed with a laser. Suturing was also done to try to strengthen the airway.

Unfortunately, his stridor returned within 2 weeks of this surgery. We are currently waiting on a follow-up sleep study, but it is believed that the revision surgery also failed. It is likely he will continue with non-invasive ventilation (NIV) via his C-Pap device to maintain his oxygen saturation levels overnight.

Our older son also has severe laryngomalacia with sleep apnea, and will likely have a supraglottoplasty in the near future.

Comments

    0 of 8192 characters used
    Post Comment

    • profile image

      Heidihoeft@gmail.com 2 months ago

      Hello, my 6 week old newborn is having the surgery next week. I haven't more than 2 hours at a time since he's been born.

      He is referred to see GI bc his throat is inflamed. They've suggested acid reflux. He has only gained one lb. since birth.

      My brother has Ehlers Danlos Syndrome and another connective tissue disorder. It has been suggested that I go through the genetic testing to see if I have anything. Do you mind sharing with the connective tissue disorder is?

      Thank you so much for this site it has been so informative for me to be able to share it with friends and family so they understand what is going on with my very noisy baby.

    • leahlefler profile image
      Author

      Leah Lefler 3 months ago from Western New York

      That is very good news. Hopefully he will simply grow out of the laryngomalacia. Truly, most children do, even though the road is hard when they are young. My son has a connective tissue disorder that complicates his situation (many of the children with very extreme cases have other contributing factors). I will say that Nolan's second supraglottoplasty was successful. He hasn't required C-Pap for several years now and is growing without support. Some children do require a second surgery, though thankfully the need for a second supraglottoplasty is rare. The support groups are very helpful, Natasha - there are a wide variety of kids and offer hope and advice from lots of parents who are struggling with this condition.

    • profile image

      Natasha 3 months ago

      Thank you for replying. I will look at the support group.

      Yes he is on the highest dose of reflux meds I believe for his age. Since surgery and taking meds his feeding has much improved. He is putting on weight now and the daily projectile vomiting/choking/gagging has almost stopped

    • leahlefler profile image
      Author

      Leah Lefler 3 months ago from Western New York

      Hi Natasha - we have found that some children have more severe or atypical cases of laryngomalacia that can linger for much longer than the "textbook 18 months." My son was unusual because he was diagnosed at age three (he had the omega shaped epiglottis that indicates he was born with it). His laryngomalacia worsened with age rather than improved - he also had very, very severe reflux that worsened the condition. MOST children do improve by the age of 2, but some do not. There are several facebook pages that are very helpful, including the Laryngomalacia Support Group. Do remember, however, that the parents of the more severe children are the ones who have a need to seek out support so the people on the support pages may not be representative of the typical experience with laryngomalacia. I will say that my son is now nearly 10 years old, and the second airway surgery helped him significantly (after having the Nissen Fundoplication). You would never know that he had such a struggle with breathing for so long. He is still very thin and struggles to gain weight, but we are able to live a very normal life now.

      I would definitely ask if he could have persistent reflux that needs to be treated (if it isn't already being addressed), because most children with laryngomalacia also have reflux - which may be "silent" reflux - and that needs treatment. The acid coming back up into the larynx can cause the floppy tissue to swell and become problematic again.

      Be vigilant and if he struggles to gain weight and continues to have breathing problems, it may be time to do another scope to determine if the laryngomalacia will be a persistent problem despite age. Hopefully he will outgrow it.

    • profile image

      Natasha 3 months ago

      Thank you for your article. There doesn't seem to be much information on the internet about Laryngomalacia... There isn't even an NHS page! All the midwives/health visitors who have been in contact with my son have not even heard of it.

      My baby had his surgery at 11 weeks old. He spent a week in intensive care and two weeks on a high dependency unit. The two months following surgery he seemed to be doing well (his stridor has never gone away though) but recently he has been admitted back to hospital twice (both times for 3 nights) as his work for breathing got quite bad again. The ENT doctors said it's because he had a virus. Anyway, the doctors have told me that his condition will self correct by the time he is 18 months / two years old.

      Reading your article, I realise that actually my son's condition could go on for longer : (

      Do you have any tips or other useful websites worth reading?