Laryngeal cleft repair: the anesthetic perspective

Abstract

Laryngeal cleft is a rare congenital malformation that is being reported with increasing frequency. Diagnosis requires suspension microlaryngoscopy under general anesthesia during spontaneous respiration. Repair may be attempted by a minimally invasive endoscopic approach or open surgical repair. The authors report on their experience with total intravenous anesthesia (TIVA) and spontaneous ventilation without an endotracheal tube during suspension laryngoscopy and CO2 laser application for this specific surgical procedure. Of particular interest were the rate at which this technique failed and rescue techniques were employed and the ability to predict patients in whom this might occur. Between July 2004 and September 2012, 110 endoscopic laryngeal cleft repairs were completed under TIVA with spontaneous ventilation without an endotracheal tube. Anesthetic induction was achieved by inhalation of sevoflurane and oxygen by mask or infusion of propofol at 300mcgkg(-1) min(-1) and remifentanil at 0.05-1.0mcgkg(-1) min. The vocal cords and surgical site were sprayed with up to 2mgkg(-1) of 4% lidocaine. If the oxygen saturation decreased during the procedure or the patient became apneic, a rescue process utilizing jet ventilation or intermittent intubation was instituted. Ten (9.1%) of the 110 cases required rescue (95% confidence interval [CI]: 5.0-15.8%). The most prevalent comorbidities included reactive airway disease, chronic lung disease, failure to thrive, developmental delay, and an unrelated syndrome. Thirty-nine patients (36%) had reactive airway disease and twelve (11%) had chronic lung disease. Intraoperative complications included six cases requiring a brief, temporary period of intubation (5.5%) and four cases requiring a brief period of jet ventilation (3.6%). The technique of TIVA with spontaneous respirations without an endotracheal tube is a safe and effective technique for laryngeal cleft repair. Although the potential for intraoperative adverse events may be high, the actual rate was very low. The need to convert to other techniques is not significant although the children who did require brief periods of jet ventilation or intubation tended to have reactive airway disease or chronic lung disease.