Supraglottoplasty Surgery for Laryngomalacia: What to Expect
Surgery for Laryngomalacia
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, and creates 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, where 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
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).
Hospital Stay Poll
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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.
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.
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Supraglottoplasty: Personal ExperiencesClick thumbnail to view full-size
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.
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