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Stridor in the Infant Patient

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Over the last 36 years, supraglottoplasty has become the surgical treatment of choice for laryngomalacia ( Fig. 7 ). The basic principles of this procedure have evolved over time, but the treatment addresses the redundant tissue along the 3 components of laryngomalacia: the epiglottis, aryepiglottic folds, and arytenoids. 16 Patients are placed under general anesthesia for the procedure, typically at the same time as a diagnostic direct laryngoscopy with bronchoscopy. After confirmation of no serious synchronous airway lesions, surgery can be performed with the patient breathing spontaneously. In patients with poor pulmonary reserve, intubation is sometimes necessary, although this can interfere with surgical exposure of the larynx. Many surgical procedures were contemplated over the past 120 years. Variot 40 in 1898 suggested excision of the aryepiglottic folds to relieve laryngomalacia-based obstruction but never performed the procedure, as his theories were based on a post mortem examination of a baby. Epiglottopexy, or the suturing of the epiglottis to the base of tongue, was described by Fearon and Ellis 41 in 1971 as a treatment for the ret roflexed epiglottis. This technique has fallen out of favor for lack of good outcomes. Seid and colleagues 42 described cutting the aryepiglottic fold for all cases of laryng omalacia, which also had limited success. Cold technique laryngoplasty was first described by Zalzal and colleagues 16 in 1987. In this technique, cold steel instruments are used to divide the aryepiglottic folds, trim the lateral edges of the epiglottis, and resect redundant supra-arytenoid mucosa, depending on which area or areas were causing obstruction. Use of CO 2 laser later became a common procedure as well. 42,43 Microdebrider-based supraglottoplasty was first described in 2005 by Zalzal and Collins 44 as an additional tool in combination with the classic cold technique supraglottoplasty (Video 1). The suction component of the microdebrider resects redundant tissue and clears blood from the laryngeal field in this technique, which al lows for a clean plane of dissection of the excess supraglottic tissue following incision of the aryepiglottic fold. 45 Recently, coblation technology has been used as another tool for operative supra glottoplasty as a safer alternative to CO 2 laser excision, as the risk of airway fires is much less. 43 However, there have not been many outcomes studies using this method over the last decade, and more research is still needed on its feasibility as a laser alternative. 46 Surgical Outcomes and Complications Overall, success rates following supraglottoplasty range up to 95%. 47 Failures are either due to technical errors, such as conservative resection of redundant supraglottic

Fig. 7. Supraglottoplasty images, before ( A ) and after ( B ) repair of laryngomalacia.

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