Endoscopic stitch repair
Cleft type: 1, 2, 3
Advantages:
Permanent aspiration solution for many patients
Relatively quick and minimally-invasive surgery
Well-tolerated by most children
Low risk profile
Disadvantages:
May not improve symptoms
Requires general anesthesia
Technically challenging
May break down and require another endoscopic repair
Other complications and risks exist
Method
An endoscopic stitch repair is performed under general anesthesia, with most surgeons preferring spontaneous respiration to avoid damaging the repair with an endotracheal tube. Spontaneous respiration also allows for better exposure. Children with significant airway anomalies should be considered high risk for difficult airway management and complications during anesthesia. ENTs need to work closely with anesthesiologists to ensure airway safety.
After the child is asleep, a laryngoscope is inserted into the larynx and suspended, allowing the ENT the ability to work with both hands. The ENT then denudes the outer layer of the cleft tissue on the sides and bottom to make it sticky and adhere better during the healing process. Denuding can be done with a laser, tiny scissors, or a combination of both. Then, the surgeon sews the cleft shut, bottom to top, using absorbable sutures and taking extra care to line up the vocal cords. This type of repair usually takes less than one hour.
Endoscopic laryngeal cleft repair.
Exposure
Endoscopic stitch repair is possible only if the surgeon can achieve good “exposure” of the cleft. If they are able to see the cleft and get their tools into the cleft area, endoscopic repair is usually preferred over an open repair. However, each child’s anatomy varies and some milder clefts cannot be repaired endoscopically because of lack of exposure or other airway anomalies. Similarly, while some type 3 clefts can be repaired endoscopically, others may need an open approach due to lack of exposure or other airway defects.
Besides lack of exposure, an open repair may be needed due to other reasons such as repeated past surgeries, TEF, and various syndromes. It’s important to understand that surgery may not always fix aspiration. Sometimes other non-anatomical conditions are causing or contributing to the swallowing difficulties.
Hospital stay
Endoscopic cleft repair is performed as an inpatient procedure. Patients usually stay in the hospital for one to three nights, depending on their recovery, bed availability, and hospital practices. Medications such as corticosteroids and antibiotics may be prescribed before and/or after the procedure based on physician preference. Some doctors will also prescribe reflux medications. Post-op diet recommendations vary per doctor.
Follow-up testing
Most doctors perform a swallow assessment after the repair, but the type and timing varies. Some patients are encouraged to try drinking thinner liquids immediately, while others are advised to wait until after a swallow assessment. Any patient that demonstrated silent aspiration before the repair should undergo an MBSS and/or FEES test at some point after the repair to determine if aspiration is still occurring. If aspiration is no longer occurring, most doctors advise following a thickener weaning protocol, to be determined and guided by the SLP.
There are many variations that occur during an endoscopic cleft repair, depending on ENT preference. As with any rare condition, it’s important to work with a surgeon and team that has experience repairing laryngeal clefts.