Clinical efficacy of transcervical epiglottopexy in infants with type Ⅲ laryngomalacia

Technical Summary: Transcervical Epiglottopexy for Type III Laryngomalacia

Problem Statement
Laryngomalacia (LM) is the most common cause of laryngeal stridor in infants, with the majority of cases resolving spontaneously. However, 12–15% of severe cases require surgical intervention. While supraglottoplasty is the standard treatment for Type I and Type II LM, it often fails to address Type III LM, which is characterized specifically by epiglottic prolapse (EP). Current treatments for EP, including endolaryngeal suturing, face significant technical challenges due to the narrow anatomical space in infants and the difficulty of achieving stable fixation. Furthermore, existing external suture techniques often require complex incisions or specialized equipment, and there is a lack of consensus on the most effective method for stabilizing the epiglottis to the tongue base without causing dysphagia or suture failure.

Methodology
This retrospective study analyzed five infants (aged 40 to 150 days) diagnosed with Type III LM caused by epiglottic prolapse, treated between October 2021 and March 2024 at Beijing Children's Hospital and Zhengzhou Children's Hospital.

The core intervention was a novel Transcervical Epiglottopexy (TE) utilizing an exo-endolaryngeal technique with readily available instruments. The procedure involved:

1. Initial Preparation: Under general anesthesia, a laryngoscope was inserted. Low-temperature plasma supraglottoplasty was performed to release shortened aryepiglottic folds and ablate mucosal tissue. In cases involving tongue root cysts (Cases 1 and 3), cyst excision was performed concurrently.
2. Suture Placement (The TE Technique):
   • Internal Component: A 5.0 Prolene suture on a laparoscopic needle was passed through the lingual surface of the epiglottis, then through the laryngeal surface, and back out to the lingual surface, avoiding the epiglottic fold.
   • External Component: A second operator used a 10 ml syringe needle to create a puncture just above the hyoid bone (external carotid area). The suture was guided through this external puncture under laryngoscopic visualization.
   • Knotting and Fixation: The suture was pulled through the neck and tied on the lingual surface of the epiglottis. To prevent friction and granulation at the external site, the suture was passed through a silicone tube and fixed at the center of the external carotid area.
   • Knotting (EK): In the initial two cases, the epiglottis was not knotted, leading to suture rupture. In subsequent cases (and a re-operation for Case 1), Epiglottic Knotting (EK) was added to secure the epiglottis to the tongue base, ensuring the suture remained taut without distortion.
3. Postoperative Care: Patients were monitored in the ICU. Extubation occurred on postoperative day 1 or 2. Follow-up included electronic nasopharyngoscopy at one month and continued monitoring until May 2026.

Key Results

• Clinical Outcomes: All five infants showed significant improvement. Laryngeal stridor resolved, and feeding, weight gain, and developmental milestones normalized.
• Suture Integrity:
  • Cases 1 & 2 (Initial): Sutures fractured one week post-operation because the epiglottis was not knotted. Case 2 improved without further surgery; Case 1 required a second TE with EK, after which the suture held for one month and symptoms improved.
  • Cases 3, 4, & 5: These cases included the addition of EK during the initial procedure. Sutures remained intact for at least one month, and all patients were successful.
• Complications: No complications such as dysphagia, aspiration, or significant swallowing dysfunction were observed. The external puncture sites healed without granulation tissue formation due to the use of the silicone tube.
• Follow-up: Patients were followed for 26 to 52 months. All children spontaneously lost their sutures at 1–2 months, with the epiglottis morphology showing knot-like changes but maintaining function.

Key Contributions and Significance
The paper claims to introduce a simplified, effective technique for treating epiglottic prolapse that addresses the limitations of both endolaryngeal and traditional external fixation methods:

• Technical Innovation: The study describes a "two-hand" technique (one operator outside the neck, one inside) using common instruments (laparoscopic needles and syringe needles) rather than specialized knotting devices or extensive neck incisions.
• Minimally Invasive: Unlike previous external techniques that required subcutaneous pockets for silicone discs and multiple incisions, this method uses a single external puncture and a silicone tube, reducing neck trauma and operation time.
• Addressing Failure: The technique proved effective in a case (Case 1) where previous supraglottoplasty and cyst resection had failed, offering a viable alternative for refractory Type III LM.
• Safety Profile: The authors report that the technique avoids the technical difficulties of intrapharyngeal suturing in narrow pediatric airways while maintaining a safety profile regarding swallowing function, consistent with findings from Kanotra et al.

Conclusion
The authors conclude that Transcervical Epiglottopexy (TE) with epiglottic knotting provides a stable fixation for the epiglottis, particularly valuable for neonates and infants where intrapharyngeal suturing is technically challenging. While the study is limited by its small sample size and retrospective nature, the authors posit that this method offers a simpler, safer, and effective alternative for managing epiglottic prolapse, especially in cases where standard supraglottoplasty has failed. They call for further studies with larger cohorts and longer follow-up to fully characterize the technique's long-term efficacy compared to other methods.