Laryngeal Clefts

The Benjamin-Inglis classification should be modified to include a type 4 long category because type 4 could be proximal above the carina, at the carina, or go straight through the carina.

The Cincinnati mass closure technique for laryngeal clefts is based on the same concept as endoscopic tracheoesophageal fistula repair: achieving raw-against-raw tissue contact, as mucosa is a non-stick surface.

KTP laser or CO2 laser can be used to remove mucosa broadly during endoscopic laryngeal cleft repair; the specific laser type does not matter.

Open repair is reserved for cases with failed endoscopic repair, some type 2s and type 3s, and uses a Larena-Fisher approach; type 4s require a cervical approach.

Type 4 long clefts present anesthetic challenges requiring double lumen tube, single lung ventilation, ECMO or bypass for surgery.

Type 4 long clefts often have associated microgastria and multiple other congenital anomalies that may drive decision-making about attempting repair.

Type 4 long clefts have a very high mortality rate of approximately 50%.

The Cincinnati technique is a reliable, simple, fast method of endoscopic repair for type 1, type 2, and often type 3 laryngeal clefts, and deep notches.

A deep notch is not an anatomical cleft but a physiological cleft; what matters is whether the patient is aspirating, not whether it is classified as type 1 versus deep notch.

The aryepiglottic folds must be released after laryngeal cleft repair because the procedure slightly cones up the larynx.

Mucosa can be removed using scissors or laser; the tool choice depends on what works in the surgeon's hands.

Open repair is considered for more severe clefts, usually type 4s; most type 3s are attempted endoscopically unless there is a reason to go open.

The transtracheal technique for open repair involves forming layers between trachea and esophagus, sewing the esophageal layer with knots in lumen, sewing the tracheal layer with knots in lumen, and optionally using an interposition graft.

The novel Cincinnati technique for type 4 long clefts involves transecting the trachea at the lower border of the cricoid, peeling the trachea off the esophagus beyond the cleft while keeping the patient intubated into one bronchus.

After tracheal transection, the esophageal hole is repaired with optional second imbricating layer, the larynx can be lifted to continue repair up to the arytenoids, and an interposition graft (typically sternal periosteum or tibial periosteum) is placed.

After esophageal repair and interposition grafting, the back of the trachea is sewn up with the endotracheal tube still in it, reconnected to the larynx by intubating from above, and a tracheostomy is placed relatively late at 2-3 weeks.

ECMO can be used for type 4 long cleft repair because it makes the procedure easier.

Aortopexy may be performed during type 4 long cleft repair.

All children with type 4 long clefts have a very short trachea, requiring the tracheostomy to be placed incredibly high, sometimes through the cricoid.

A cuffed endotracheal tube can be placed in the esophagus to demonstrate the location of a tracheoesophageal fistula.

Transtracheal 3-layer closure can be performed for tracheoesophageal fistula with extremely thin mucosa.

Endoscopic repair of residual tracheoesophageal fistula is difficult in younger children but feasible in a 6-year-old.

Endoscopic tracheoesophageal fistula repair uses Bugby cautery to demucosalize the tract, then places an endoscopic suture to ligate the tract and achieve raw-against-raw contact without saliva or air movement.

Endoscopic suture placement for tracheoesophageal fistula uses a P2 needle on 40 PDS and is a surprisingly difficult procedure.