Author(s)
Daniel C. Schmidtman, MD1
Mateo Useche2
Brhanu H. Asgedom, MD3
Cody Messick4
Nasser Lubega, MD1
Joshua P. Wiedermann, MD1
Affiliation(s)
1. Department of Otolaryngology – Head and Neck Surgery, Mayo Clinic, Rochester, MN
2. Harvard T.H. Chan School of Public Health, Boston, MA
3. Department of Otolaryngology – Head and Neck Surgery, Ayder Comprehensive Specialized Hospital, Mekelle, Ethiopia
4. Mayo Clinic Alix School of Medicine, Scottsdale, AZ
Abstract:
Introduction
Laryngeal clefts are rare congenital anomalies of the posterior laryngeal framework resulting from incomplete separation of the trachea and esophagus. Symptomatic patients present with dysphagia and chronic aspiration. Left untreated, there is potential for development of recurrent aspiration pneumonia and chronic interstitial lung disease. They are most frequently categorized using the Benjamin & Inglis grading system. Types I–II clefts are typically treated endoscopically and Types III–IV traditionally require open repair, though advances in endoscopic technology and technique have allowed for successful treatment of Type III clefts. This case highlights the utility of an open approach in the setting of failed endoscopic management and the feasibility and importance of adapting complex airway surgery to resource-limited environments.
Case Description
We present a two-year-old male from the Tigray region of Ethiopia with a Type III laryngeal cleft. A tracheostomy was placed prior to definitive management to help with aspiration and improve pulmonary hygiene. The cleft was initially repaired endoscopically, but wound dehiscence occurred within several months, resulting in return of symptoms. Though a repeat attempt at endoscopic repair was considered, a laryngofissure approach was performed and the cleft was repaired in a layered fashion due to patient and system factors. At the time of repair, a gastrostomy tube was placed. The patient recovered uneventfully with a structured postoperative plan for airway surveillance, nutritional monitoring, and family counseling.
Discussion
This case highlights the utility of an open approach in laryngeal cleft repair, particularly in cases of prior unsuccessful endoscopic repairs or when specific contextual factors necessitate it. In this case, dehiscence of the endoscopic repair was likely influenced by pre-operative nutritional status, lack of NPO adherence following the initial endoscopic repair, and persistent gastroesophageal reflux. Definitive open repair using a laryngofissure approach allowed direct visualization, multilayer closure, and interposition graft placement, offering a durable solution despite resource limitations. To minimize the need for a separate surgical site, sternal periosteum was used as the interposition graft. This case underscores the ongoing role of open repair in select patients and illustrates the feasibility of adapting complex pediatric airway surgery to resource-limited environments.