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Zalzal & Zalzal

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mucosa or epiglottic cartilage, or to inherent patient characteristics. A systemic review by Preciado and Zalzal 46 found that failure in infants is significantly associated with chil dren with neurologic and medical comorbidities compared with those without. Complications following supraglottoplasty are rare, but include aspiration, supra glottic stenosis, cartilage damage, airway fires, and granuloma formation. 5 Inflamma tion and airway edema are transient issues that may develop in the immediate postoperative period but can be controlled with an adequate postoperative medica tion regimen. The most serious complication, supraglottic stenosis, is a rare occur rence that will require repeat operative resection of scarring and monitoring to prevent further narrowing of the airway. Practice management for children who undergo surgical treatment for laryngomalacia involves multiple factors. In 2016, a survey of 101 otolaryngologists who perform supraglottoplasty shared their strategies for postsupraglottoplasty care. Most patients will receive perioperative steroids to help with postoperative laryngeal edema, with several undergoing a taper of steroids for several days postoperatively. 43 Depending on physician preference, antibiotics are prescribed postoperatively, with most who do prescribe antibiotics given at least 5 days of medical therapy. 43 Regarding acid sup pression therapy, the International Pediatric Otolaryngology Group published postop erative guidelines recommending that proton-pump inhibition or histamine-2 receptor antagonists should be continued for at least 3 months postoperatively. 34 Children should be monitored for at least 24 hours postoperatively in the event laryngeal edema worsens in that timeframe. Patient monitoring should ideally take place in a recovery room or intensive care unit setting. Nearly all patients will leave the hospital the following morning if there are no desaturation events or feeding diffi culties postoperatively. Swallowing outcomes should not be affected after the procedure if performed correctly. Patients correct immediately after the procedure. Should there be a concern for dysphagia or aspiration after the procedure, evaluation by speech therapy or eval uation with flexible endoscopy can be performed before discharge. Routine follow-up is performed within 4 to 6 weeks of the operation to confirm resolution of symptoms. 34 Repeat flexible endoscopy in clinic does not need to be performed if there is no clinical indication for the procedure. Depending on the reason for the initial consultation, both swallowing and breathing outcomes should improve by the first postoperative visit. If the patient continues to have respiratory noise when breathing or if signs of failure to thrive are still present, alternative causes for these pathologic conditions must be eval uated. This may include need for repeat direct laryngoscopy with bronchoscopy, or alternative workup for failure to thrive and swallowing dysfunction in conjunction with the patient’s primary care provider. Stridor presents as an inspiratory, expiratory, or biphasic noise owing to obstruction or narrowing somewhere along the respiratory tract. Diagnosis is dependent on visuali zation of the airway, typically by flexible fiber-optic laryngoscopy in the clinic or direct laryngoscopy with bronchoscopy under anesthesia. In some cases, a barium swallow study will be needed to evaluate cause. Laryngomalacia is the most common cause of inspiratory stridor in neonates and infants, with 10% of children having severe symp toms requiring surgical intervention. Supraglottoplasty will result in good outcomes for most children with laryngomalacia. POSTOPERATIVE MANAGEMENT SUMMARY

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