Laryngeal Cleft Repair

What is laryngeal cleft?

Laryngeal cleft, laryngotracheoesophageal cleft (LTEC), and laryngotracheal cleft (LTC) make up a spectrum of conditions that describe what happens when the airway doesn’t separate from the swallowing pathway as it normally should during development. Usually, there is a separation between the voice box and windpipe (larynx and trachea) and the esophagus, but with these conditions, there is an open connection between the two. This gap allows food, liquid, and saliva to pass through the larynx into the lungs. This can cause swallowing issues and aspiration (when food or liquid passes into the lungs), recurrent lung inflammation, and coughing and choking with feedings.

The vast majority of babies diagnosed with a laryngeal cleft are born with this condition. Occasionally, it can be caused by an airway surgery.

What are the kinds of laryngeal cleft?

  • These conditions happen in varying degrees.
  • Shallow, mild clefts that happen at the vocal cord level are very common.
  • Deeper, more severe clefts that extend down to the trachea or down into bronchi are less common.

At Lucile Packard Children’s Hospital Stanford’s Aerodigestive and Airway Reconstruction Center, we have expertise in repairing all kinds of clefts, from mild to severe. We work closely with the cardiac surgery team and have extensive experience in open and endoscopic airway reconstruction.

How is the condition diagnosed?

  • Deeper, severe clefts are often diagnosed right away when a baby is born and has problems with feeding and breathing.
  • People with shallow clefts may not have any symptoms, and the cleft may be found later in childhood or even in adulthood.
  • Clefts can be misdiagnosed. Children who wheeze and don’t respond to asthma treatment may actually have a laryngeal cleft, not asthma.
  • The condition is sometimes associated with other syndromes.

What is the treatment?

Our approach is to consider both nonsurgical and surgical options after discussing a child’s options with our otolaryngology (airway surgery), pulmonary (lung), gastrointestinal (GI), nutritional, and speech-language pathology specialists. We work very closely with parents (and the patient, if old enough) to establish goals for the child, and we take pride in shared decision-making.

Minor clefts

  • If the cleft is minor, we often follow the child closely to see how the swallowing matures over the first few years.
  • Among the nonsurgical treatments, feeding strategies are often used. These include pacing feeds or using a data-driven approach to thickening the feeds. Thickening feeds facilitates safe swallowing by slowing the speed of the liquid as it passes into the esophagus, reducing the risk of aspiration through a cleft.
  • For some patients, we perform a simple procedure to inject filler to fill the cleft. These fillers last a few months and buy time while the patient’s swallowing matures. This may be all the treatment that is needed.
  • For patients with more severe or bothersome symptoms, we often do minimally invasive repair through the mouth. This takes 25–30 minutes in most children.

Conditions that need surgery

Patients with complex voice and swallowing disorders are also seen in our Pediatric Voice and Swallowing Clinic or in our Aerodigestive and Airway Reconstruction Program. These multidisciplinary clinics cater to the needs of children with complex breathing and swallowing concerns, and our team takes into account both the child’s immediate needs and future needs, such as his or her voice.

  • If surgery is needed, the goal is to repair the airway through airway reconstruction surgery to improve swallowing function while preserving breathing and voice.
  • Some minor clefts are treated endoscopically (though the mouth without making incisions). In many cases, more severe clefts can also be repaired endoscopically.
  • For deep, complex clefts, we do an open repair (not endoscopic), often through a neck incision. For very deep clefts, we do the repair through the chest. For these most complex cases, we bring together a team of otolaryngologists who specialize in treating airway disorders, cardiothoracic surgeons, cardiac intensive care specialists, and cardiologists to closely collaborate and to develop a surgical plan. We have dedicated multidisciplinary aerodigestive surgeons who work together to perform complex repairs with an integrated approach, which leads to excellent outcomes for patients.
  • In severe cases, a patient sometimes needs a tracheostomy. In these cases, the goal is to help the repair heal, and then to remove the tracheostomy tube.

What happens after the surgery?

After minor repairs, children usually do very well and can eat and breathe well. We reevaluate the child’s swallowing about six weeks after surgery.

After more complex repairs, children go to one of our intensive care units (ICUs), where they are cared for by a team trained to manage patients after this surgery for a few days to a few weeks, depending on the kind of repair. After a child has recovered from surgery, the Aerodigestive and Airway Reconstruction Center physicians and therapists evaluate and optimize breathing, speaking, and swallowing.

The team then follows patients over time, including telehealth visits, to make sure these functions continue to do well and to make sure that patients reach their fullest potential.

Our patients may be seen at other programs at Packard Children’s, including the Pediatric Voice and Swallowing Clinic, Pulmonology, Pediatric Heart Surgery, and Gastroenterology, Hepatology and Nutrition.