Bipolar Cautery as a Simple Yet Effective Technique for Epiglottopexy in Laryngomalacia

Laryngomalacia is the commonest cause of infantile stridor [1]. Most cases of laryngomalacia are managed expectantly, with 10%–20% being severe and requiring surgical intervention [2]. Indications for surgery include cyanotic episodes, apnoea, increased work of breathing, sternal recession, feeding difficulties, failure to thrive and supplementary oxygen requirements. The routine standard for surgical treatment of severe or complicated cases is supraglottoplasty, which can utilise cold and hot techniques to reduce excessive arytenoid mucosa (type 1 supraglottoplasty), divide tight aryepiglottic folds (type 2 supraglottoplasty) or reduce epiglottic collapse (type 3 supraglottoplasty) [3]. Numerous techniques have been described for reducing epiglottic collapse over the laryngeal inlet, including the use of heat in the form of coblation [4, 5] or laser vaporisation [6, 7] of the lingual aspect of the epiglottis, with [4, 6] or without [5, 7] suturing to the tongue base. We present a modified version of applying heat to the epiglottis with bipolar cautery as a simpler technique to achieve epiglottis anteriorisation. The surgical technique used by the senior author (A.J.D.) is bipolar cautery to the lingual surface of the epiglottis. Patients are anaesthetised with spontaneous ventilation without endotracheal intubation, delivering oxygen via an oropharyngeal or nasopharyngeal airway. All patients undergo a full airway endoscopic examination to confirm the diagnosis and rule out other synchronous airway anomalies. Patients are suspended with a paediatric laryngoscope positioned in the vallecula, and the laryngoscope is slightly withdrawn to allow the posterior tongue to drop into the field of view and improve access to the vallecula. Bipolar cautery (Covidien Valleylab FT10, 6 - 8 W) is briefly applied to the lingual surface of the epiglottis to curl it away from the laryngeal inlet (Figure 1). This is accompanied with mucosal blanching and coagulation. Case notes for patients who had undergone the described procedure were retrospectively assessed for the period January 2019—July 2022. Fifteen patients were identified as a retrospective single surgeon case series in a single centre. No ethical approval was required as this did not deviate from the standard of care offered by the senior author and represented a service evaluation. The process guidelines for reporting were followed. The patient characteristics are summarised in Table 1. Of the 15 patients, none (0%) of the patients were syndromic, while one (6.7%) patient had significant respiratory comorbidity. The most common co-morbidity was reflux, present in 8 of the 15 children (53.3%). The median age of surgical intervention was 4 months (interquartile range [IQR] 7 months, range 0–22 months). No child needed intensive care post-operatively. Twelve (80%) children were admitted for one night post-operatively. The other three patients stayed for between 3 and 21 days, the latter being due to respiratory comorbidities needing separate management. One child (6.7%) required a second procedure for ongoing symptoms after the initial intervention. Another child was later found to have bilateral abductor weakness, requiring tracheostomy. Vocal cord movements were seen during the original microlaryngotracheobronchoscopy when the aryepiglottoplasty was performed, highlighting how challenging a diagnosis can be when there are other synchronous airway abnormalities. The abductor weakness spontaneously resolved, and the patient was successfully decannulated within a few months. However, this unusual evolving case was not a complication of the surgery as the recurrent laryngeal nerves would not be encountered during the procedure. Four children (26.7%) had a synchronous airway abnormality (vallecula cyst, grade 1 congenital subglottic stenosis, tracheomalacia and bronchomalacia). No children developed new aspiration concerns post-operatively. Seven children (46.7%) were already on thickeners pre-operatively for symptoms of reflux. The patients in this series have been followed up for a median of 15 months (IQR 13 months, range 4–44 months) to date. All children were documented to have clinical improvement in their airway symptoms following surgery. We describe a technique to achieve lingual curvature and lift of the epiglottis to open the laryngeal inlet that, to our knowledge, has not been reported before. Epiglottopexy techniques utilising coblation [4, 5] and lasers [6, 7] have previously been published. Hazkani et al. [4] used either a coblator or CO2 laser to denude the mucosa of the vallecular sulcus and epiglottic surface, followed by placing a single absorbable suture to anteriorise the epiglottis. This technique was combined with type I or II supraglottoplasty as indicated for each case. Patients remained intubated for at least 24 h and received a dose of steroids. In their series, 92% (12/13) of patients required only one procedure for laryngomalacia, but 30.8% (4/13) developed new aspiration concerns. El-Sobki et al. [5] reported a technique of trimming the epiglottis with coblation and creating a raw area over the base of tongue and lingual aspect of the epiglottis to promote adhesion via scar formation. Patients received 1 week of antibiotics, and the authors reported a 70% (7/10) success rate for this technique in their larger report of their coblation techniques for all three types of supraglottoplasty. Whymark et al. [7] reported a technique of applying a carbon dioxide (CO2) laser in a linear fashion to the lingual surface of the epiglottis to achieve curling away from the laryngeal inlet. This technique necessitates an operating microscope, laser equipment and microlaryngeal instruments and reported a 73% (43/59) success rate with one procedure. Werner et al. [6] reported a small case series of six patients, where a CO2 laser was used to vaporise the lingual aspect of the epiglottis and base of tongue. The authors then placed three absorbable sutures to oppose the epiglottis to the base of tongue. All children in this series received perioperative antibiotics. Werner et al. reported a 100% success rate after one procedure, and none of the children developed swallowing issues post-operatively. The need for laser equipment, coblation wands, operating microscopes and overnight intubation in intensive care significantly adds to the cost of the above described techniques. In contrast, bipolar cautery is comparatively more affordable and practical, without the same risk of airway fires of laser-utilising techniques. Application of bipolar cautery as we have described will likely have a lower risk of supraglottic scarring than other common supraglottoplasty techniques as it is only applied to one surface. Bipolar cautery application is also simpler technically and the described technique is relatively quick to perform in theatre compared to more complex approaches. Our technique would be very appropriate for developing countries due to the less burdensome equipment requirements. Most the patients (86.7%) in this series had more than one type of supraglottoplasty performed in the same procedure to address the type of laryngomalacia present, highlighting that the chosen technique needs to be based on the endoscopic findings. This fits well with the theory of limiting the surgery to accommodate the individual case and demonstrates well how laryngomalacia can exist in different forms. The technique we describe appears to be effective as 93.3% of patients required only one procedure, as well as being safe as no patients developed aspiration symptoms. M.R. acquired and analysed data. M.R. and A.J.D. drafted and revised the manuscript. A.J.D. performed the technique. A.J.D. and M.R. approved the manuscript. The authors declare no conflicts of interest. The peer review history for this article is available at https://www.webofscience.com/api/gateway/wos/peer-review/10.1111/coa.14216. The data that support the findings of this study are available from the corresponding author upon reasonable request.