Laryngeal Cleft: The Basics

[Dr. Hamdy El-Hakim]
I usually start by saying that the esophagus and the trachea or the windpipe and the gullet initially were one project, and they usually decide to split and go their own ways in terms of the role for swallowing and breathing. Laryngeal cleft is essentially a low ramp in between the two entries, and it can get deeper and deeper, and the lesser fortunate are the ones who have a deeper one.

In terms of swallowing, I always like to explain to them that swallowing is a sequential domino-like process that basically starts in the mouth and ends up hopefully in the stomach safely. It has many factors that affect it, and we really need to take a holistic approach to the child. We need to make sure that breathing and swallowing are taken for granted and smooth as vision and hearing and a heartbeat. In terms of the structural abnormality, I don't talk about the structural abnormality until I find one.

[Dr. Gopi Shah]
In terms of classification, if you're teaching the residents or your fellow, how do you describe the classification?

[Dr. Hamdy El-Hakim]
I think the classic classification into four grades. I know that there are sub-classifications, but at the end of the day, the golden rule is never to depend on a flexible endoscopy. You have to do a rigid endoscopy. You have to instrument. It takes really no skill at all to pick grades two, three, and four, and lucky enough, they are pretty rare. If somebody talks about vast experience, I think they'd be lucky or maybe unfortunate. In terms of laryngeal cleft type one, it always reminds me of the myth of Loch Ness Monster to some extent. Some people say that they have seen it for certain, and others say it was the effect of the Scottish whiskey.

[Dr. Hamdy El-Hakim]
A general exam is a good idea, and I think pediatric otolaryngologists need to always understand that they are dealing with children who need some form of developmental assessment, and their communication, their general demeanor tells them a lot. A child who is not feeding properly is a child that is not generally very happy, not very relaxed. Subtle dysmorphic features are pretty important. You may be dealing with a syndromic child. You're not going to diagnose the syndrome quite often, but you can tell if the child has some dysmorphic features related to your area.

The other feature is testing for tone, because if the child has a low tone in the end, you can expect a few problems. The second issue is after you ensure that you have an oral cavity that is within average, that you have gone through the nose and you expected patency before you leave the nose you should, I feel that whereas the young child, you cannot always tell a submucous cleft trans-orally you can actually tell that the child has a submucous cleft with a telescope a lot better. Because you're going to see the nasal septum rather than inserting itself at right angle onto the floor of the nose, it will be flying in the breeze and creating a bit of an acute angle. You will see that at the nasal side of the soft palate.

FEES to me is the queen. Not biased towards the kings and males. The queen of all examinations. You really need to see whether you have an open and patent velopharynx or not, and competent one. Sometimes, the first thing that is secretions inside the nose, saliva as a matter of fact forming, not discharge. Certainly if a little bit of in fact secretions in the nose especially in an infant, this is not a usual finding. This is telling you that there might be some nasopharyngeal escape. Then when you look at the larynx, in an infant in particular, we all know that the larynx is a bit high and the epiglottis usually gives you the high five.

Definitely before you even notice the base of tongue, you should see the epiglottis. If the epiglottis being hugged by the tongue base and the tongue base is slightly higher, your odds of finding an anterior larynx is pretty high. That particular risk factor, if you ask about risk factors, that is almost, in my opinion, a slam dunk. You're going to find a problem that needs a bit of rehabilitation there. The way the larynx and the hypopharynx handles salivary secretions is very important. There are no benchmark classifications. There is one from the adult world, purely subjective as any other endoscopy, and then you need to draw on your experience in laryngology.

The FEESer needs to be really an accomplished laryngologist. The child is not always incredibly happy, although we have advanced. Initially, we never tried with toddlers, but now, we do it with them and we have our own ways of entertaining them and convincing them diplomatically that we're doing well and we mean well. You determine whether you have malacia or not, you determine whether you have a movement disorder or not. I use that word in particular rather than talking about paralysis. Then you start your show with the feed, which the child really needs to play ball with it, and some of them definitely will say, "Not today. Don't try."

I do not forget to auscultate. That's something that we forget as an art. It tells us a few things. Certainly tells us whether the lower airway is affected or not, it tells us whether it's purely upper airway, not purely of course, but it definitely does help. A good proportion of my patients also were dysphonic, and that's the other thing, that the parents will quite often tell you, upon asking, "The child's voice is weak."