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Table. Summary of Studies on Supraglottoplasty Outcomes a

Mean Age at Surgery, d

Mean Follow-up, mo

Source

Location

Technique

Sample Size

Day et al, 11 2012

United States

CO 2 laser Cold steel

74

116.5

NR

Eustaquio et al, 12 2011 Rastatter et al, 5 2010

United States United States

CO CO

2 laser

75 39

135

8

2 laser Cold steel 2 laser Cold steel Cold steel CO

NR

NR

Hoff et al, 13 2010

United States

56

NR

NR

Richter et al, 14 2009 Groblewski et al, 3 2009 Denoyelle et al, 4 2003

United States United States

50 28

136 182 120

NR

Microdebrider

6

France

CO 2 laser Cold steel

136

NR

Senders and Navarrete, 10 2001

United States

CO

2 laser

23

60

10

Abbreviations: CO 2 , carbon dioxide; NR, not reported. a The method of data collection in all studies was retrospective.

number of patients in each study was 60.1 (range, 23 136), and the mean age of the patients at the time of su praglottoplasty (in studies inwhich it was annotated, k=6) was 124.9 days (range, 69-182 days). The average length of follow-up after supraglottoplasty was 8 months (k=3 studies). Of the 8 studies identified in the literature that met the inclusion criteria listed in the Table, only 6 had sufficient information to extract comparable measures on the primary outcome of surgical success by the pres ence of associated comorbidities. Eustaquio et al 12 pre sented data on aspiration risk only, without specific in formation as to “surgical success” by associated comorbidity. Similarly, Rastatter et al 5 presented data relative to aspiration risk but not to surgical success by associated comorbidity. Only 3 studies had sufficient information to extract comparable measures on the pri mary outcome of aspiration risk by presence of comor bidities. Random-effects modeling was performed to estimate surgical success rates comparing patients with isolated laryngomalacia with those with associated comorbidi ties. The overall risk ratio of surgical failure among pa tients with significant associated comorbidities com pared with those with isolated laryngomalacia was 7.14 (k=6 studies; 95% CI, 3.73-13.74; P .001) ( Figure 1 ), significantly demonstrating the risk of surgical failure in patients with associated comorbidities. The risk ratio for persistent or significant aspiration after supraglotto plasty among patients with associated comorbidities com pared with those with isolated laryngomalacia was 4.33 (k=3 studies; 95% CI, 1.25-15.06; P = .02) ( Figure 2 ), also demonstrating a significant rate of persistent or new aspiration in patients with associated comorbidities. There appeared to be no difference in outcome by surgical tech nique or by age at surgery, although there were insuffi cient data reported to calculate the relative risk by those variables. RANDOM-EFFECTS MODELING OF PRIMARY SURGICAL OUTCOME MEASURES

METHODS

PubMed was searched for multiple specific search terms. The search periodwas from January 2001 to February 2012. No other databases were included. The specific search terms used were supraglottoplasty , epiglottoplasty , and laryngomalacia . The fol lowing inclusion criteria were then applied: English language, human subjects, and outcome data. No age criteria were ap plied. Studies that directly reported on the failure of surgery were included, regardless of the surgical technique that was used. Articles that did not include discreet metrics were excluded (no mention of number of success or failures or patient categori zation by associated comorbidities). As mentioned, multiple su praglottoplasty techniques (microdebrider, laser, cold steel) were included, as the goal was to assess the risk of supraglotto plasty failure rather than the instrumentation used to perform it. The results of these studies were summarized in an evi dence table and analyzed, with primary outcome measures of surgical success and rate of chronic aspiration as reported by each article. Surgical failure was defined as the need for revi sion surgery, tracheostomy tube placement, or gastrostomy. Sub group analysis was then performed with the same outcomes comparing patients with significant associated comorbidities with those without associated comorbidities. Significant co morbidities were extrapolated from each study included and were defined as cardiac, neurologic, or gastrointestinal. All stud ies included a minimum of 10 patients. No prospective con trolled studies were found in the literature. Only case-control and retrospective case series studies were identified and in cluded in this analysis. Statistical analysis was performed with statistical software (MIX 2.0 PRO, Version 2.0.1.4; BioStatXl). Random-effects modeling was used to calculate summary ef fect measures (risk ratio) with corresponding 95% confidence intervals, and Forest plots were generated. P .05 was consid ered significant.

RESULTS

LITERATURE SEARCH

Using the aforementioned search criteria, 12 articles were initially identified. Eight studies met the inclusion criteria ( Table ). 3-5,10-14 All identified studies were retrospective in nature (retrospective case-control studies, level 4). Themean

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©2012 American Medical Association. All rights reserved.

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