David E. Tunkel, MD; Karin S. Hotchkiss, MD; Stacey Ishman, MD; David Brown, MD


November 26, 2008


Laryngomalacia is usually a self-limited condition, but it can be associated with gastroesophageal reflux, neuromotor disease, and obstructive apnea.[4,5] Infants with severe laryngomalacia may require supraglottic surgery to prevent the consequences of neonatal upper airway obstruction.

Holinger described several patterns of inspiratory supraglottic collapse, one or more of which are found in each infant with laryngomalacia: inward aryepiglottic fold collapse (type 1), tubular epiglottic shape (type 2), anterior-medial collapse of the arytenoids (type 3), posterior epiglottic displacement (type 4), short aryepiglottic folds (type 5), and an acutely angled epiglottis at the petiole (type 6).

The mainstay of surgical treatment has been resection of the aryepiglottic fold.[1,3] Resection of a portion of the aryepiglottic fold has been shown to be effective,[6] but simple incision of the aryepiglottic fold improved almost 90% of children with severe laryngomalacia in one series.[7] The need to lengthen the aryepiglottic fold is highlighted by Manning and colleagues,[8] who found lower aryepiglottic fold length-glottic length ratios in children requiring surgery for laryngomalacia when compared with controls.

Supraglottoplasty has been performed with "cold" microsurgical instruments and the CO2 laser.[9] Supraglottic stenosis and interarytenoid adhesion have been described as complications, scarring that has a much poorer prognosis than laryngomalacia itself. Kelly and Gray used unilateral supraglottoplasty as a means of reducing the potential for such complications, although staged surgery on the second side was required in 3 of their 18 patients.[10] Conservative, precise tissue division or removal seems prudent.

The advantages of using through-cutting sinus forceps to incise/excise aryepiglottic fold tissue in infants with laryngomalacia are listed in the Table . The length of conventional sinus through-cutting forceps, about 11 cm, is ideal for use with the neonatal Benjamin-Parsons laryngoscopes, particularly when compared with 22-cm microlaryngeal scissors. The procedure can be performed on both sides in a few minutes, without special equipment such as lasers, microdebriders, or laser-safe endotracheal tubes.

The procedure is enhanced, rather than encumbered, by the use of an endotracheal tube, providing greater safety for neonates with lung disease or severe gastroesophageal reflux who need maintained airway control. Tissue excision is precise and limited when using the through-cutting forceps. We expect this limits granulation and scarring.

The limitations of this procedure are several. Laryngomalacia that involves posterior displacement of the epiglottis (Holinger type 4) may not be completely relieved by aryepiglottic fold division, although we have rarely seen this occur in otherwise healthy infants.[11,12,13] The presence of marked supra-arytenoid mucosal collapse (Holinger type 1) may require resection in addition to aryepiglottic fold division.


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