Practice patterns in supraglottoplasty and perioperative care

Abstract

Objectives Supraglottoplasty is the first-line surgical treatment for severe laryngomalacia. The purpose of this study is to determine current trends of practice patterns in management of children requiring supraglottoplasty. Methods A 25-question survey on management in supraglottoplasty was sent by e-mail to 274 physician members of the Society for Ear, Nose & Throat Advances in Children (SENTAC). Results 101 surgeons responded and 72% of respondents were in academic practice (p < 0.0001). All four United States regions, Canada and the United Kingdom were represented. The most commonly reported age of patients undergoing supraglottoplasty was 1–3 months (62% of respondents). Indications include worsening airway symptoms (43%), failure to thrive (41%) and worsening feeding (10%). The majority of respondents (89%) treat these patients for reflux with 54% prescribing PPIs and 41% prescribing H2 blockers. Cold steel is the most popular surgical technique (73%) followed by laser (14%), microdebrider (10%) and coblator (3%) (p<0.0001). Most respondents (92%) administer intraoperative steroids with the majority of them choosing dexamethasone (99%). Perioperative antibiotics are administered by 23% of respondents. Almost all respondents admit their patients for post-operative observation (99%) and 53% of these admit to PICU rather than step-down or floor status. The level of care is associated with the number of supraglottoplasties performed per year (p=0.009) and with the geographic region (p=0.02). Surgeons who perform fewer supraglottoplasties tend to admit to a higher level of care. Those in the South and Northeast regions tend to admit more to floor status. Only 13% routinely keep patients intubated post-operatively. Conclusions This provider survey study highlights some significant variations and trends in practice patterns of otolaryngologists who perform supraglottoplasty. The majority utilizes anti-reflux pharmacotherapy; however, there is no consensus in the type. The method for supraglottoplasty also varies with cold steel being the most popular, although no single method has been shown to be superior. There is variation in post-operative care with trends for keeping patients extubated and admitting them to an intensive care. With the importance of safe, effective, and also cost-conscious care, further studies are needed to understand the optimal management of those who undergo supraglottoplasty.

Harmonic Shears in the Surgical Treatment of Laryngomalacia

“…The clinical evaluation of respiration and feeding was the only criteria for discharging children. Other studies also report that postoperative flexible fiberoptic laryngoscopy is seldom performed and quite preferred [11]. The absence of postoperative endoscopic evaluation due to ethical concerns may be regarded as a weakness of our study.…”

“…Nowadays, the instrumentation used in these types of interventions includes a cold knife, microdebriders, a coblator, or a laser [9-10]. Ultracision Harmonic shears (Ethicon Inc., NJ, US) were supposed to be useful in this condition, but no clinical evidence is reported in the literature [11].…”

Laryngomalacia: is there an evidence base for management?

“…A survey of USA, Canadian and UK practice examined the management of reflux associated with severe laryngomalacia requiring surgery 59 . Of 101 respondents, only 89 per cent would treat for reflux, 54 per cent with proton pump inhibitors only and 41 per cent just with H 2 blockers.…”

“…Indications for surgery are subjective and rarely documented, centring on the worsening of an ill-defined variety of airway symptoms (especially cyanosis and apnoeic episodes), feeding difficulties and failure to thrive 59 …”

Endoscopic Laser Cordotomy Versus Coblator Cordectomy: Our Experience in Managing Bilateral Abductor Paralysis

“…patients with obstructive sleep apnoea syndrome, the use of coblator in the management of bilateral abductor paralysis is scarcely reported. [10][11][12][13] The reported advantage of coblator over CO 2 laser is a minimal surrounding tissue charring and damage owing to a lesser rise in temperature in the adjacent tissues. 13,14 This property of coblator is also responsible for a lesser postoperative edema and an early decannulation.…”